Suicide and self-harm

Suicide and Self-harm

(This chapter is also available as a PDF here)

The aim of this needs assessment is twofold: firstly, it serves as the final chapter of the overarching Cambridgeshire and Peterborough Mental Health Needs Assessment, summarising the state of data and evidence on self-harm and suicide prevention; secondly, it aims to inform the update of the Cambridgeshire and Peterborough Suicide Prevention Strategy and enhance our understanding of the needs of individuals who self-harm.

This needs assessment contains frequent references to suicide, self-harm, associated risk factors, and details regarding the means and methods of suicide. Please seek advice and support if you feel affected by any of the issues discussed. For mental health crisis help, please see mental health helplines below or on the Keep Your Head webpage.

Scope

This chapter covers the needs of Cambridgeshire and Peterborough (C&P) residents who:

  • Have suicidal or self-harm thoughts
  • Have self-harmed
  • Have attempted suicide
  • Have died from suicide
  • Families/ carers of individuals with suicidal or self-harm thoughts, who self-harm, have attempted suicide or have died from suicide

Henceforth, these groups collectively are referred to as “people affected by self-harm and suicide”.

Outside the scope of this needs assessment are:

  • Crisis service review, which is currently being undertaken by Cambridgeshire and Peterborough Integrated Care Board (ICB).
  • Service capacity and waiting times analysis
  • Implementation / budget constraints

Key findings

All graphs are for this needs assessment are included in the data pack below:

The data presented in this needs assessment carry significant data caveats. While data on deaths from suicide are generally reliable, interpretation of small number changes requires caution. Data on suicide attempts, suicidal thoughts, and self-harm is limited and less precise. Most individuals who self-harm do not seek medical help, so hospital data represent only a small proportion of actual cases. Furthermore, routine hospital records do not distinguish between self-harm and suicide attempts.

Table 1 summarises the crude C&P estimates for Self-Harm, Suicidal Ideation, Suicide Attempts based on national survey data. The scale of these estimates highlights that self-harm, suicidal ideation and suicide attempts constitute a significant public health concern.

 

Table 1: Estimating Local Numbers for Self-Harm, Suicidal Ideation, Suicide Attempts based on national survey data

Self-harm data

  • Data across national surveys consistently highlight that self-harm predominantly affects children and young people (ages 10-24), with significantly higher levels seen in females than males. Latest data estimates that the prevalence of adults who have ever engaged in self-harm is around 6.4% (2014 APMS) vs 36.8% for young people aged 17 to 24 years (2023 MHCYP) and 45.7% for young women (2023 MHCYP).
  • Nationally, there is some evidence that reported self-harm is increasing among young people. However, local Health-Related Behaviour School Survey data indicate that reported self-harm in Peterborough has remained stable between 2022 and 2024, while Cambridgeshire has experienced a slight decline.
  • Local hospital data shows that both A&E attendance and hospital admissions for self-injurious behaviour have been on a consistent decline.
  • Locally, there was a very small proportion of patients (less than 1% of total patients) who attended more than 10 times and accounted for 12% of the total A&E attendances.
  • From local liaison psychiatry data review of ‘self-injurious behaviour’, A&E attendances are coded as relating primarily to suicide attempts, ideation, and overdoses rather than non-suicidal self-harm, consistent with national findings that hospital data underrepresents non-suicidal self-harm.

Suicidal ideation

  • From national data, it is estimated that a fifth of adults (20.6%) had thought of taking their own life at some point in their lives (APMS 2014). There were no national estimates available for children and young people.
  • Nationally, key risk factors were living alone, out of work, receiving benefits (two-thirds of Employment and Support Allowance (ESA) recipients had suicidal thoughts (66.4%) and approaching half (43.2%) had made a suicide attempt at some point).
  • There was no local data for estimating the prevalence of suicidal ideation in C&P as a whole, although from local Liaison Psychiatry data, a high proportion of A&E attendances for self-injurious behaviour related to suicidal ideation.

Suicide attempts

  • From national data, it is estimated that one adult in fifteen (6.7%) had made a suicide attempt at some point in their life (APMS 2014).
  • Despite men being more likely than women to die from suicide, women were more likely to report having ever attempted suicide (APMS 2014).
  • Locally, the rate of s136 orders has significantly declined in C&P. From 2018/19 to 2023/24, Cambridge City consistently reported the highest s136 rate among all local authorities in Cambridgeshire and Peterborough. Females aged 10-19 were 3.5 times more likely to be placed under s136 compared to their male counterparts, unlike national trends. Moreover, the gender disparity has widened over time, with females constituting an increasingly larger proportion of s136 orders.

Deaths from suicide

  • In 2022, there were 65 local suicide deaths, a crude rate of 8.21 per 100,000 people, aligning with the England average. This rate remained consistent from the previous year, 2021, with 65 deaths (8.21 crude rate), and was slightly higher in 2020 with 70 deaths (8.84 crude rate).
  • The local suicide audit reveals that suicides generally do not have a single cause but are the result of a complex interaction of factors. The most common risk factors that could be determined based on coroner files were:
    • Demographic and current circumstance factors – male, middle-aged, lived alone, separated, or unemployed.
    • Mental Health – the majority had a formal mental health diagnosis (60%); depression and anxiety were most common diagnosis for those where it was recorded.
    • Social and Economic factors – relationship breakdowns, work, and financial issues.
    • 45% had a history of self-harm.
    • 44% involved drugs or alcohol.
    • 28% reported ongoing physical health issues
    • 15% had adverse childhood experiences
    • 15% had contact with the criminal justice system.
    • 10% involved domestic abuse
    • 10% were believed to be neurodivergent (including autism and ADHD)
    • 5% involved bereavement
  • In terms of healthcare contact, local audit data showed that in the month prior to their suicide around a third saw their GP and around a quarter were in contact with mental health services. Around three quarters saw their GP in the six months prior to their suicide.

Wider impact

  • Self-harm not only affects the individual but profoundly impacts their family and carers, leading to emotional upheaval, strained relationships, and social isolation due to stigma, underscoring the need for supportive interventions for both individuals and their families.
  • It is estimated that each suicide affects up to 135 people, leaving deep emotional scars and significantly increasing the risk of suicide among the bereaved, highlighting the necessity for comprehensive postvention support and suicide prevention strategies within communities.

Lived experience

Reviews of national and local research identified the following themes relating to people’s experiences of self-harm and/or suicide:

  • Reluctance to Disclose Self-Harm: Many young people feel hesitant to disclose self-harm to an appropriate adult due stigma surrounding self-harm and the unclear procedures and fear of the consequences from disclosing self-harm behaviours. This issue is exacerbated by a lack of open communication and fear of embarrassment or misunderstanding within their support networks.
  • Diverse Manifestations of Self-Harm: Self-harm behaviours vary widely, including physical harm like cutting, as well as risky behaviours such as picking fights or excessive drinking, with differences observed between genders.
  • Range of wider needs (Self-Harm and Suicide): A significant number of individuals express a wider range of wider needs, some of which relate to historic negative experiences (such as traumatic experience in childhood) and others are more recent (such as job loss). Another common issue was feelings of loneliness, lacking supportive networks, which often leads to stress, low mood, and even suicidal thoughts.
  • Service Access and Quality Challenges (Self-Harm and Suicide): Long waiting times, high thresholds for support, unclear expectations about available support, and lack of adequate follow-up care are commonly expressed, making it difficult for individuals to access and receive continuous care.
  • Trauma-informed care (Self-Harm and Suicide): Many individuals report unresolved traumas affecting them into adulthood, highlighting the need for trauma-informed care that considers past experiences without necessitating their repeated disclosure.
  • Positive Relationships and Effective Support (Self-Harm and Suicide): Positive outcomes are often linked to supportive relationships with health professionals and effective communication. The availability of coping strategies, interpersonal and peer support, and positive relationship with staff and personalised care (including talking therapies and medication) were highlighted as important for recovery.
  • Systemic Barriers and Trust Issues (Self-Harm and Suicide): Barriers to accessing support, such as unawareness of services, and not feeling listened to by staff, can lead to distrust in the healthcare system, preventing people from being able to access the right support.

Risk factors

The occurrence of self-harm and suicide stems from a complex interplay of mental and physical health issues, psychological conditions, social interactions, and cultural factors, rather than a single cause. This can include:

  • Differences in Risk Profiles: Self-harm shows higher prevalence among girls and women, whereas suicide rates peak among middle-aged men, frequently connected to economic issues such as financial instability and housing difficulties.
  • Poor Predictive Value of Previous Self-harm and Psychiatric Factors: while previous self-harm and suicide attempt are important risk factors for suicide, the vast majority of people who experience suicidal thoughts or engage in self-harm behaviours do not proceed to suicide. Similarly, although psychiatric conditions are common among individuals who demonstrate suicidal behaviour, they do not consistently predict suicide attempts, highlighting the need for broader risk assessment approaches.
  • Genetic and Societal Contributions: There is no definitive genetic predisposition identified for suicidal behaviour, and the quantification of social determinants as contributors to self-harm remains imprecise.
  • Risk and Protective Factors: Identified risk factors include demographic characteristics (gender, age, LGBTQ+ status), substance misuse, adverse life events (financial strain, abuse, bullying), and wider determinants like socio-economic disadvantage. Evidence on ethnicity as a risk factor is varied. While some data suggest that young women from ethnic minorities may have an increased risk of self-harm, national surveys on suicidal ideation show no significant differences in rates among ethnic groups after adjusting for age. National suicide data indicates that suicide rates are highest among the White and Mixed/Multiple ethnic groups and lowest in the Arab group. Locally, suicide rates are notably higher among individuals born in the EU, especially those from Lithuania. Protective factors encompass coping skills, problem-solving skills, restricted access to means of harm, social support, and access to mental health services.
  • Local Variations in Peterborough: Peterborough has significantly higher suicide risk factor rates than Cambridgeshire and the England average in several areas, including the estimated prevalence of common mental disorders (19% vs 14%), rates of children entering the youth justice system (4% vs 2%), marital breakup rates (14% vs 11%), and unemployment rates (7% vs 3%). In addition, the gap between the high estimated prevalence and lower recorded QOF prevalence of common mental health disorders suggests a significant unmet need in Peterborough.

Self-harm prevention evidence

  • Limited Prevention Guidance: Current NICE guidelines primarily address secondary-tertiary prevention, focusing on interventions post-presentation of self-harm rather than preventing the initial occurrence.
  • Assessment and Long-term Support: Recommendations stress the importance of psychosocial assessments, maintaining therapeutic relationships, and establishing long-term care plans for those who decline specialist referrals.
  • Cultural Reset: Efforts should be made to reduce the social influences of self-harm, which are shaped by broader cultural trends, as exposure to self-harm through others can increase the likelihood of engaging in similar behaviours. It is essential to maintain a balance in how self-harm is discussed publicly, ensuring it is neither stigmatised nor glamorised, and to increase the availability of adaptive coping strategies.
  • Treatment Approaches: Treatments range from psychological therapies like CBT and DBT, which can reduce self-harm repetition in adults and frequency in youth, to brief safety interventions and pharmacological approaches with varying degrees of evidence. Additionally, peer support plays a crucial role by providing alternative expressions of distress and fostering long-term recovery.
  • Primary prevention: Includes enhancing societal and economic conditions, implementing supportive policies in families, schools and other education-based settings, and fostering peer support networks.
  • Lived Experience: Individuals with lived experience of self-harm should be actively involved in leading, designing, delivering, and evaluating care services to ensure that these services meet the actual needs of those they aim to help.

Suicide prevention evidence

  • WHO and NICE Guidelines: Recommend actions like limiting access to means, responsible media reporting, and fostering socio-emotional skills, complemented by comprehensive strategies involving multi-agency suicide prevention partnerships that focus on governance and local data to effectively reduce access to means and involve families in care processes.
  • Education and Means Restriction: Educating healthcare providers widely in depression management, implementing mental health education in schools and other education-based settings, and employing means restriction to limit access to common suicide methods.
  • Consistent Follow-Up: continuous follow-up for psychiatric patients post-discharge or during suicide crises.
  • Treatment approaches: Dialectical and cognitive behavioural therapies are highlighted as effective for managing suicidal behaviours, with emphasis on developing coping mechanisms and psychotherapeutic management.
  • Primary Care: Primary care involvement in suicide prevention is crucial as in the UK over 90% of individuals who die by suicide visit their GP in the year preceding their death.
  • Lived Experience: Successful implementation of interventions greatly benefits from the involvement of individuals with lived experiences.

Local stakeholder survey

A survey of local stakeholders identified the following strengths and gaps in service provision:

  • Service Clarity and Support: The survey revealed highest ratings for the clarity of where to refer and the quality of crisis support.
  • Praised Services: Respondents praised several services, including crisis intervention, community mental health services, school support programs, and the Personality Disorder Community Service.
  • Challenges in Coordination and Family involvement: Coordination between service providers and the involvement of families and carers were the most poorly rated areas.
  • Identified Gaps: Key gaps identified in the services include long waiting times for community mental health and crisis support and lack of early intervention measures. Specific concerns were raised about inadequate support for families and vulnerable groups such as those affected by substance abuse, neurodivergent individuals, those with learning disabilities, and residents of certain geographic areas. Additionally, follow-up support post-crisis was deemed insufficient.
  • Awareness of Suicide and Self-Harm Prevention Services: While 98% of respondents were aware of Samaritans, many were unaware of other local offers (75% were unaware of ‘Ask Me How I Am’, 58% were unaware of Lifecraft’s bereavement support, and 46% were unaware of both Lifeline and STOP Suicide training).

Recommendations

Further Research and Data Enquiries

  • Continuous Data Update: Update this report upon the release of the new Adult Psychiatric Morbidity Survey (2023/4) expected in June 2025. This survey is crucial for providing updated estimates on self-harm, suicidal ideation and suicide attempts, as the current report relies on data from the 2014 APMS Survey. Also revise the estimates for children and young people when the next Mental Health of Children and Young People in England survey data become available, although no release date has been announced yet.
  • Trends in Hospital Attendance and Admissions: Investigate the reasons behind the consistent decline in local A&E attendance and hospital admissions for self-injurious behaviours. Explore whether this reflects a genuine reduction in need, perhaps due to improved community support and increased demand in VCSE sectors, or other factors such as long wait times or changes in recording practices.
  • Section 136: Explore why locally women aged 10-19 are 3.5 times more likely to be placed under section 136 than males, with the gender gap widening over time, which contrasts national trends. Link Police and CFPT insights on the needs of these individuals.
  • Service Capacity and Waiting Times: Assess waiting times and the balance of demand versus capacity in services supporting individuals affected by self-harm and suicide.
  • Self-harm recording: Explore whether local hospitals record self-harm incidents similarly by considering an audit and engaging with staff who work across NWAFT and CUH.
  • Demographic Differences: Better understand the reasons behind self-harm predominantly affecting young girls and women and higher suicide rates among middle-aged men to tailor and enhance mental health interventions for these specific groups.
  • Seasonality in FRS data: Better understand the possible reasons for seasonality in FRS call data and if it is displayed in other mental health services and what would be practical actions from this.

Data collection

  • Comprehensive and Consistent Data Collection on Self-Harm: Aim for alignment across NHS, public sector, and voluntary/community organisations in collecting data on self-harm, with and without suicidal intent, noting it as a secondary or additional concern if it is not the primary reason for service interaction. This approach should include a standardised method for separating and recording these incidents to facilitate easy coding and extraction. Additionally, it is recommended to routinely collect data on associated risk factors such as ethnicity, gender identity, autism, and adverse childhood experiences to enhance understanding and improve targeted interventions.
  • Data Recording Across Local Hospitals: Currently, CUH and NWAFT have differing categorisation systems used by psychiatric liaison, which are not directly comparable and hinders understanding the prevalence of self-harm vs suicidal ideation and underlying mental health needs. Harmonise the categorization of self-harm, suicidal ideation, suicidal attempts, and mental health diagnoses within secondary care.
  • Ambulance Data Collection: Implement a consistent data collection strategy across ambulance services for callouts related to self-harm, with and without suicidal intent (currently no data available) and whether they led to a hospital visit. This would be useful for capturing incidents of self-harm that do not lead to A&E visits or hospital admissions, thus filling a gap in hospital data.
  • Data from primary care: Primary care data is currently limited to coroner’s inquests for this needs assessment. Future efforts should focus on improving access to primary care data to better understand self-harm and suicide as primary care is often the main healthcare contact.
  • Ethnicity recording: To better understand local inequalities in suicide and self-harm, improve ethnicity recording, potentially using primary care records for consistent coding.

Services and Commissioning

  • Psychosocial assessments: Conduct comprehensive, person-centred psychosocial assessments for the care and treatment of individuals at risk of suicide, focusing on the quality of the therapeutic relationship. NICE has highlighted the flaws in suicide risk prediction and the need to replace risk prediction, including risk stratification, with a psychosocial approach (NICE NG225).
  • Primary care: Emphasise the importance of primary care in the prevention and management of self-harm (NICE NG225) and suicide risks and that each interaction with a person struggling with their mental health represents an opportunity to inquire about suicidal ideation (NICE NG222 1.2.8; NICE NG225 1.13.5). Continue to support primary care providers with the necessary resources and training to handle these sensitive interactions effectively as currently done through Fullscope’s ‘Ask Me How I Am’ self-harm training and CPSL Mind‘s ‘Suicide Awareness and Response in Primary Care Training’. Additionally, increase the involvement of primary care in suicide prevention strategies (1).
  • NCISH audit: mental health care providers should use the ‘Safer Services toolkit,’ developed by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), for ongoing and at least annual self-assessments to enhance patient safety and reduce suicide rates.
  • Psychological Treatments for Self-Harm: use therapies like Cognitive Behavioural Therapy (CBT) and Dialectical Behaviour Therapy (DBT), which have been shown to be effective in reducing self-harm repetition in adults (2). While DBT may not decrease self-harm repetition in children and adolescents immediately, it can help reduce the frequency of self-harm over time (2).
  • Equity of CYP bereavement support across C&P: Currently, Lifecraft provide bereavement support across C&P for people aged 17+ and STARS provide bereavement support for people aged 4-19 in Cambridgeshire, but there is a gap in support for young people in Peterborough. Considering making bereavement support more widely available, including in schools and colleges, and to identify and monitor those at increased risk.
  • Frequent A&E Attenders: Investigate the needs of the frequent A&E attenders for self-injurious behaviour (locally, ~1% of patients attended more than 10 times per year and account for 12% of the total A&E attendances).
  • Follow-up Care: Enhance follow-up care for individuals who have attempted suicide or are engaging in ongoing self-harm. Ensure that support is also accessible to those contemplating self-harm or suicide to prevent attempts as a means of accessing help.
  • Lived Experience and Peer Support: Incorporate insights from those with lived experience in designing, delivering, and evaluating self-harm and suicide prevention services. Enhance peer support to aid long-term recovery.
  • Family and Carer Involvement: Ensure that all services are supported to engage with and provide support for families and carers who often have insights into the suicidality and self-harm of their loved ones not shared with professionals (NICE QS189; NICE NG225).
  • Mental health support for at-risk groups: Link suicide prevention efforts with domestic abuse services and integrate mental health support with life-changing physical health diagnoses.
  • Service Awareness: Increase the visibility and awareness of local suicide and self-harm prevention services, addressing the low awareness of offers like ‘Ask Me How I Am’, Lifecraft’s bereavement support, Lifeline, and STOP Suicide training.
  • Dual Diagnosis: Improve the integration of services for individuals with substance misuse issues and mental health services, ensuring referrals can be made directly from mental health to drug and alcohol services and vice versa.

Prevention Strategies

  • Loneliness and Isolation: Develop a local strategy to support individuals experiencing loneliness, isolation, and relationship breakdowns, which are significant risk factors both for suicide and self-harm. Enhance public mental health initiatives that support for those navigating relationship challenges to mitigate these risk factors effectively.
  • Linking Suicide Prevention with Poverty Reduction: Integrate suicide prevention efforts with local initiatives addressing poverty, focusing on individuals who are out of work, unemployed or on benefits.
  • School Support Programs: Strengthen school and other education setting-based mental health programs to potentially reduce self-harm rates and improve children and young people’s mental health. Initiatives could include supporting peer-based help programs like Youth Aware of Mental Health and Teen Mental Health First Aid, workforce development to equip staff with better understanding and response strategies for self-harm, and implementing anti-bullying measures. While school support was highlighted in our stakeholder survey, evidence on effectiveness of such programs is currently limited. Robust local evaluations are required to assess their impact comprehensively.

Local suicide audit and strategy

  • Commitment to sustained suicide prevention funding: Ensure the continuity of a suicide prevention lead within the Integrated Care System, alongside ongoing funding for prevention programs. This would support leadership stability, enhance strategic planning, and guarantee the provision of essential services such as bereavement support.
  • Scope of Self-Harm in Suicide Prevention: Assess the scope of self-harm within the suicide prevention strategy, given that most self-harm is non-suicidal. While self-harm and suicide share common risk factors (e.g., LGBTQ+, loneliness and socio-economic deprivation), the fundamentally different age and gender profiles involved necessitate tailored services and approaches.
  • Dedicated analytical support for suicide audit: To ensure robust statistical analysis in suicide audits, dedicated analytical support is crucial for implementing statistical methods such as calculating confidence intervals and preventing overinterpretation of numerical changes as significant findings.
  • Assess and address discrepancies in risk factors between the local audit and literature: Review the highlighted areas of discrepancy in the risk factor summary and advocate for their inclusion and monitoring where possible, e.g., recording of disability and benefit status, which are significant risk factors nationally but not recorded / available in the local audit.
  • Strategic Alignment: Align the local suicide prevention strategy with:
    • This needs assessment’s recommendations, based on epidemiological data, evidence on prevention, lived experience, and stakeholder survey insights.
    • National priorities (focusing on supporting vulnerable groups, addressing common risk factors, providing bereavement support, and promoting community-wide responsibility for suicide prevention)
    • Local suicide prevention strategy evaluation (greater resources, aftercare for people who have self-harmed, addressing stigma around self-harm and suicide)
    • Local suicide audit recommendations (follow-up care after suicide attempts, relationship breakdown support, lived experience involvement, recording of suicide intent in self-harm episodes, direct referrals to drug and alcohol services, mental health support alongside life-changing physical health diagnosis, suicide prevention support to domestic abuse victims)
    • Domestic Homicide Review Panel recommendations (family and parental support following suicide training for professionals; collaboration between suicide prevention and domestic violence and abuse services; tailoring suicide prevention to different groups like people with autism, learning disabilities, and LGBTQ+; workplace engagement in suicide prevention).