Prevention

Prevention

  • Understanding risk factors associated with suicide and self-harm is the cornerstone of effective prevention strategies.
  • Modifiable risk factors (e.g., lifestyle choices, employment) provide valuable insights for shaping prevention programs, while non-modifiable risk factors (e.g., age, gender) guide efforts to identify and support high-risk population groups.
  • There is rarely one single cause of either self-harm or suicide. Instead, both self-harm and suicide are the result of a complex interplay between underlying health needs (mental or physical), psychological, social, cultural, and other factors.
  • It is important to highlight that most risk assessment tools rely heavily on demographic and mental illness indicators, reflecting broad population trends over a lifetime. While these tools may support population-level prevention initiatives, they fall short of accurately predicting suicide in individuals at specific moments and the use of risk assessment tools is against NICE guidelines (18).

Risk and protective factors

Table 5 below summarises the risk and protective factors identified in the literature and data reviewed for this this needs assessment, particularly NICE (7), CDC (19) and The Lancet Commission on self-harm (2). Many factors are common to both self-harm and suicide, such as stressful life events, social isolation, and physical or mental health challenges. However, key distinctions exist. For example, self-harm is more prevalent among young women, while suicide rates are higher among middle-aged men. Various structural factors, including disproportionate exposure to gender-based violence such as domestic abuse and sexual harassment, often result in trauma that can lead to self-harm as a coping mechanism, contributing to higher rates of self-harm among women compared to men (2). Additionally, financial instability, housing difficulties, and employment challenges are more frequently associated with suicide than with self-harm. It is also crucial to note that psychiatric risk factors are poor predictors of suicidal behaviour. Although the majority of individuals who die by suicide have a mental disorder, suicidal thoughts are not always indicative of mental illness (9). Research suggests that mental illness is more strongly associated with suicidal ideation than with actual suicide attempts (9).

From the field of genetics, no specific genes have been conclusively identified as conferring risk for suicidal behaviour (2). There also remain fundamental gaps in our knowledge about societal contributors to self-harm. We know that various social determinants contributes to self-harm in a broad sense, however a precise quantification of their relative contribution and to what degree they act synergistically is missing (2).

Given the complex interplay of multitude of factors, effective prevention and intervention strategies for self-harm and suicide need to be multifaceted.  These strategies should also address various dimensions of inequality, including socioeconomic deprivation, equality and diversity factors, and challenges faced by disadvantaged groups, as detailed in the Inequalities chapter of the MHNA.

National risk factor data

Readily available national data on suicide prevention focuses on some mental health issues and social factors, which is a small subset of al the risk factors (Figure 2). For Cambridgeshire, all of the risk factors are either better or similar to England average. For Peterborough, several risk factors are significantly higher (worse) than England average – high rates of common mental disorders (2017), high rates of children entering youth justice system (2020/21), high rates of marital breakup (2011), and high rates of unemployment (2021/22). In Peterborough, the gap between the high estimated prevalence and recorded QOF prevalence of common mental health disorders suggests a significant unmet need. (Note QOF prevalence refers to the proportion of patients within a practice’s registered population diagnosed with certain conditions, as recorded through the Quality and Outcomes Framework.)

Figure 2: Suicide risk factors, C&P compared to England. Source: Fingertips

Fullscope’s self-harm research

Fullscope’s 2022 review of self-harm prevalence in Children and Young People highlighted evidence on specific groups who are at particularly high risk of self-harm:

  • Adolescent girls (as consistent with national survey and hospital data above)
  • LGBTQ+ – 61% of gay, lesbian and bisexual young people have self-harmed at some point. This jumps to an alarming 84% of trans young people.
  • Ethnic minority groups – there is some evidence that young women from ethnic minorities are at heightened risk of self-harm (22) although APMS 2014 data suggest that lifetime suicidal thoughts, attempts and self-harm rates did not differ significantly by ethnic group after age-standardising the data.
  • Autism – There is an emerging evidence which suggests that levels of self-harm among young autistic people are very high.
  • Socio-economic deprivation – one study showed that the proportion of children under 12 who self-harm living in neighbourhoods ranked most deprived (43.4%) was twice the national average.

Evidence base for prevention

Table 6 summarises key interventions for self-harm and suicide prevention discussed in the literature below, categorised by the following levels:

  • Primary prevention (usually universal): These interventions aim to prevent self-harm and suicide by addressing broader risk factors in individuals who currently do not exhibit suicidal or self-harm thoughts.
  • Secondary prevention (targeted): This level focuses on preventing self-harm and suicide attempts among those at higher risk (e.g., those with suicidal ideation) or who show early signs of distress.
  • Tertiary prevention (targeted): These interventions target individuals who have already self-harmed or attempted suicide. They provide aftercare to prevent repeated self-harm and suicide attempts and offer support to families and those bereaved by suicide.

Table 6: Prevention evidence summary

Self-harm prevention

There is significant lack of guidance on the primary prevention of self-harm as NICE guidelines (summarised above), focus on interventions once someone has already presented with self-harm (secondary-tertiary prevention). Key recommendations from NICE include:

  • Ensure that a psychosocial assessment has been carried out by a mental health professional (18) or in primary care with appropriate training (23) and manage and follow up in primary care for those who decline specialist referral, maintaining continuity of therapeutic relationships wherever possible. Ensure there is longer-term care plan and ongoing support (NICE) (7,23). Note: A psychological assessment is a comprehensive assessment including an evaluation of the person’s needs, safety considerations and vulnerabilities that is designed to identify those personal psychological and environmental (social) factors that might explain an act of self‑harm.
  • Treating self-harm behaviour involves gradually replacing coping through self-harm with less harmful strategies. This work should be undertaken in collaboration with clinicians with specialist training in self-harm. It can be counterproductive to simply forbid the person to engage in self-harm or remove their access to methods of self-harm (9).

In 2024, a comprehensive review of self-harm was published in The Lancet (11), synthesizing a wide range of empirical research and the lived experiences associated with self-harm. The review recognises that self-harm with a fatal outcome (i.e., suicide) has received considerable clinical and policy attention, while self-harm more generally has been neglected by governments internationally. The review highlights significant findings and outlines evidence-based strategies for prevention and intervention. The critical insights from the report underscore the complexity of self-harm behaviours and suggest multidisciplinary approaches to address both the symptoms and underlying causes effectively. Key findings and recommendations are summarised below.

  • Poorly Understood: Evidence is scarce on how individual factors and social contexts interact to influence self-harm, or on predicting when an individual might be more likely to engage in self-harm.
  • Social and Psychological Factors: Numerous psychological and social factors are associated with self-harm and the social determinants of health. In particularly, poverty heavily influences the distribution of self-harm within communities.
  • Stigma and Misunderstanding: Self-harm is heavily stigmatized, often linked to broader mental health stigmas and exacerbated by its visible and deliberate nature, which draws parallels to other stigmatized behaviours like substance misuse.
  • Clinical vs. Lived Experience: While psychological treatments may benefit some individuals who self-harm, there is often a discrepancy between what service users and practitioners consider effective treatment. Additionally, there is a fundamental tension between clinical perspectives and the lived experiences of those who self-harm, as they may not always prioritize treatment and prevention as primary goals.
  • Cultural Trends: Self-harm is influenced by broader social and cultural trends, including social relationships and class dynamics. Exposure to self-harm through others, often via social learning, can increase the likelihood of engaging in similar behaviours. The widespread availability of visual depictions of self-harm online could enhance its appeal as a coping strategy. Although social media is frequently criticised for its impact on mental health, it also offers benefits such as online support networks that provide emotional support, advice, understanding, and a sense of belonging for those who feel isolated.
Self-harm management
  • Psychological Treatments: Therapies such as Cognitive Behavioural Therapy (CBT), Dialectical Behaviour Therapy (DBT), mentalization-based, and emotion-regulation therapy have shown promise in reducing self-harm repetition among adults. Dialectical behaviour therapy in children and adolescents does not appear to reduce repetition of self-harm but could reduce frequency of self-harm over a longer period of time.
  • Brief and Safety Interventions: Techniques like safety planning may help in mitigating self-harm incidents.
  • Pharmacological Approaches: Some medications may reduce the repetition of self-harm, though the evidence base remains weak.
  • Supportive Technologies: There is little to no evidence on the effectiveness on app-based interventions.
  • Peer Support: For many people who self-harm, the development of alternative forms of expression of distress might be best supported by the peer groups who intimately understand the experience. While specific evidence on self-harm is limited, recent reports indicate a strong demand for peer-supported services, emphasizing their value in therapeutic approaches that fosters recovery through long-term, peer-to-peer relationships beyond crisis intervention.
Primary Prevention
  • Societal and Economic Improvements: Enhancing social determinants like employment, minimum wage, and government spending on social welfare and labour market programs, along with improving healthcare access, social connectivity, and economic stability, has been shown to be crucial for suicide prevention and is expected to similarly reduce self-harm rates. However, evidence directly linking these factors to reductions in self-harm is currently limited.
  • Supportive Policies for Families and Schools: Initiatives aimed at supporting families, enhancing school and other education setting-based mental health programs, and implementing anti-bullying strategies are anticipated to lower self-harm incidents. However, the evidence on their direct effectiveness in reducing self-harm remains sparse.
Service Delivery and Recommendations
  • Lived Experience Leadership: 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.
  • Professional Training: Healthcare and social care professionals need comprehensive training in the compassionate assessment and management of self-harm to better understand and address the complexities of this issue.
  • Integrated and Comprehensive Care: A coordinated, multidisciplinary approach is crucial for meeting the complex clinical, social, and economic needs of those who self-harm. This involves forming specialist teams that work across traditional healthcare boundaries, such as primary and secondary care, acute care, and mental health services, ensuring continuity of care.
  • Responsible Media Representation: Media outlets should promote healthy coping strategies and avoid content that either stigmatises or glorifies self-harm. Harmful depictions of self-harm methods should be avoided, while promoting helpful information such as self-regulation strategies, crisis resources, and messages of hope.
  • School-Based Interventions: School and other education setting-based programs should focus on staff training, supporting staff to better understand self-harm, identifying and supporting at risk students and referring them to specialised services where appropriate. Supporting peer-based help, like Youth Aware of Mental Health and Teen Mental Health First Aid, is also crucial, although well-evaluated, self-harm-specific programs are still limited. Locally, Fullscope is currently developing resources to help secondary school-aged young people understand self-harm.
  • 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 (Figure 2).

Figure 2: Self-harm communication (2)

  • Data-Driven Approaches: Developing robust systems to monitor self-harm trends and the effectiveness of interventions is essential for making informed decisions and adjusting strategies based on empirical evidence.

Suicide prevention

At an international level, the WHO published a global imperative in 2014 and continues to encourage governments to implement the LIVE LIFE package of evidence-based interventions for suicide prevention, which includes 4 key parameters (24):

  1. Limit access to the means of suicide;
  2. Interact with the media for responsible reporting of suicide;
  3. Foster socio emotional life skills in adolescence;
  4. Early identification, assessment, management, and follow up of anyone who is affected by suicidal behaviours.

NICE guidelines on suicide prevention state that there should be 5 actions to prevent suicide (these are very similar to the WHO recommendations above):

  • Multi-agency suicide prevention partnerships have a strategic suicide prevention group and clear governance and accountability structures.
  • Multi-agency suicide prevention partnerships reduce access to methods of suicide based on local information.
  • Multi-agency suicide prevention partnerships have a local media plan that identifies how they will encourage journalists and editors to follow best practice when reporting on suicide and suicidal behaviour.
  • Adults presenting with suicidal thoughts or plans discuss whether they would like their family, carers or friends to be involved in their care and are made aware of the limits of confidentiality.
  • People bereaved or affected by a suspected suicide are given information and offered tailored support.

For healthcare services, the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) have developed the ‘Safer Services toolkit’ with 10 evidence-based recommendations for services to improve patient safety and reduce suicide rates (25). These are illustrated in figure 6 below.

Figure 3: Safer Services: 10 key elements for safer care for patients

A systematic review of suicide prevention strategies has identified evidence supporting four main approaches based on their efficacy and scalability (26):

  1. Educating primary care physicians and other non-psychiatric specialists like internists and obstetrician-gynaecologists in depression management.
  2. Implementing mental health education for high school students and considering expansion to college students.
  3. Employing means restriction to limit access to common methods of suicide.
  4. Enhancing predischarge education and ensuring consistent follow-up for psychiatric patients after hospital discharge or during a suicide crisis.
Additional relevant literature highlights
  • An umbrella review of treatments of suicidal behaviours (27) found that dialectical and cognitive behavioural therapies are highlighted as the most effective methods for treating and managing suicide attempts and suicidal ideation. Key interventions include the provision of coping tools, techniques focusing on thoughts and behaviours, and the use of behavioural, psychoanalytic, and psychodynamic therapies to manage emotions.
  • A review of facilitators and barriers to the implementation of suicide prevention interventions concluded that involving people with lived experience across all stages of the implementation process are key to successful services (1).
  • There is strong evidence that openly discussing suicide does not induce suicidal thoughts but rather facilitates disclosure and progression towards recovery (9).
  • Over 90% of individuals who die by suicide have interacted with their GP in the year before their death, underscoring the importance of suicide awareness and intervention training for all primary care practitioners (9). This is consistent with local suicide audit findings.

Additional resources