4 th Annual Forum Wednesday 2 nd September 2009 Royal Hospital Kilmainham “Suicide Prevention – Working Together”

1. 4th Annual Forum Wednesday 2nd September 2009 Royal Hospital Kilmainham “Suicide Prevention – Working Together”

2. Implementation of a Suicide Supportand Information System:a pilot study Dr Ella Arensman, Dr Carmel McAuliffe, Eoin O’Shea, Dr Paul Corcoran, Eileen Williamson National Suicide Research Foundation 2nd September 2009 The study has been commissioned by the National Office for Suicide Prevention

3. Research priorities NSRF in line with priorities of Reach Out The National Strategy for Action on Suicide Prevention, 2005-2014 - Suicide risk identification - Standardisation of suicide bereavement support Suicide ca 500 p.a. • - Standardised assessment • of DSH • Efficacy of treatments • for DSH patients • -Restricting access to means Deliberate self harm medically treated ca. 11,000 p.a. “ - Evidence based mental health promotion “Hidden” cases of Deliberate self harm ca. 60,000 p.a.

4. Suicide in Ireland by age and gender, Average rates 2002-2006

5. Trends in undetermined deaths for men and women in Ireland (1996-2005)

6. Suicide Support and Information System: a pilot-studyObjectives • Improve provision of support to the bereaved • Better define the incidence and pattern of suicide in Ireland • Identify and better understand causes of suicide • Identify and improve the response to clusters of suicide, filicide-suicide and familicide The objectives are in line with Reach Out, the Seventh Report of the Houses of the Oireachtas Joint Committee on Health and Children, and the Form 104 Report

7. Background Scoping exercise 2006 • Literature review • Consultation with relevant agencies and professionals: - Coroners - Department of Justice - CSO - Gardai - National Confidential Inquiry into Suicide and Homicide, Division of Psychiatry, University of Manchester - National Drug-Related Deaths Index, HRB

8. Recommendations based on Scoping Exercise • Need for more information on risk and protective factors associated with suicide in general and for specific groups in Ireland, e.g. - deliberate self harm patients - psychiatric inpatients - psychiatric patients recently discharged from in-patient care - marginalised groups / those from an ethnic minority • More information is required on clusters of cases of suicide, filicide-suicide and familicide • Coroner service should be linking in more closely with bereavement support services to facilitate support to family members and friends

9. Recommendations • In some cases lack of information to determine verdict of suicide / accident / homicide • Currently still many pressures - not to include the verdict of suicide – (from gardai, family members due to stigma around suicide). Suicide cases involving single RTA’s may be underestimated • A minority of people who died by suicide (ca. 24%) were known to be in contact with mental health services in the year prior to their death. In obtaining a complete picture of suicide cases it is therefore important to also involve other health care professionals and agencies, e.g. coroners, GPs, gardai; and also family members or friends.

10. Obtaining a more complete picture of the suicide case using relevant sources of information GP/Psychiatrist/ Psychologist Coroners’ verdict records & Post mortem reports Gardai Close family members/friends

11. Suicide Support and Information System: a Pilot-Study – a stepped approach(September 2008- May 2010) Inquest concluded involving cases of suicide /other sudden deaths Step 1- Support: SR facilitates support for families bereaved by suicide / other sudden deaths after conclusion of inquest Step 2 - Research: SR will approach next of kin and health care professional(s) after conclusion of inquest SR: Senior Researcher

12. Screening for possible cases of suicideCase finding criteria • Sudden deaths recorded as open verdicts, drownings and single vehicle road traffic accidents • Screening criteria: - Explicit verbal or nonverbal expression of suicide intent - Inappropriate or unexpected preparations for death - Expression of farewell, desire to die, hopelessness, great emotional or physical pain - Precautions to avoid rescue - History of deliberate self harm acts or threat - Serious depression or mental health problems - Stressful events or significant losses Rosenberg et al, 1988 Often insufficient evidence is available to determine a verdict of suicide / accidental death

13. Information to be obtained from Coroner Service after conclusion of inquest:Verdict records and post-mortem reports - Checklist Core data items: • Socio-demographic information • Information on cause of death • Presence of suicide note / text message • Mental health problems • History of non-fatal suicidal behaviour (deliberate self harm) • Physical illness • Treatment history: in/outpatient care • Alcohol and drug abuse • Use of medication • Toxicology results in relation to alcohol, drugs and poisons • Suicide / deliberate self harm by family members / friends • Events leading to suicide / probable suicide: Background stressors and precipitating events

14. After appropriate support has been provided, a family member will be invited to participate in a semi-structured interview* Core data items: • Situation around time of death / events leading to death • Presence of suicide note / text message • Family and personal history • Life events and history • History of non-fatal suicidal behaviour (deliberate self harm) • Suicide / deliberate self harm by family members / friends • Treatment history in the year before death: in/outpatient care, number of psychiatric admissions, compliance with treatment • Physical illness • Alcohol and drug abuse • Social network *According to guidelines based on psychological autopsy studies

15. Information to be obtained from health care professionals who had been in contact with the deceased within 12 months prior to death – Semi-Structured Questionnaire Core data items: • Socio-demographic information • Information on cause of death • Presence of suicide note / text message • Events leading to suicide / probable suicide: Background stressors and precipitating events • History of non-fatal suicidal behaviour (deliberate self harm) • Family and personal history • Mental health problems • Physical illness • Alcohol and drug abuse • Treatment history: in/outpatient care, number of psychiatric admissions, compliance with treatment, recently discharged • Use of medication • Final contact with services prior to death: estimate of immediate suicide risk, estimate of long term suicide risk, suicide thought to be preventable • Additional information • Additional information

16. Progress so far • 2007/2008: Consultation with Coroners in Co. Cork • Dec 2008: Approval Coroners Society Ireland • Jan. 2009: - Ethical approval - Training workshop with Coroners and their staff • Feb 2009: Start pilot study in collaboration with Coroners in Co. Cork • Data collection Type 1: Inquests between Sept ’08 – March ’09 • March 2009: Start data collection Type 2: Inquests between March ’09-April ‘10

17. Response • 6 out of 73 (8.2%) persons indicated that they did not wish to be further approached after having received the first letter. • Referral to bereavement support after conclusion of inquest out of N=67: - Yes: N=17 (25.3%) - No: N=21 (31.3%) - Remainder N=35, the majority of those who have only recently been contacted, and those who are not applicable (e.g. misadventure, non-English speaking, inquest not finalised). • 17 interviews completed so far (Non-response: 12 refusals i.e. individuals who refused interview or who did not respond to follow-up calls). A further N=36 are in progress (contact ongoing).

18. Challenges • Interdisciplinary approach: Collaborative structure including Coroners, GPs and mental health care professionals, Gardai • Legislation: Submission to New Coroners Bill by the NSRF is currently being considered • Following a local pilot study, development of a National Suicide Support and Information System

19. For further information contact: Dr Ella Arensman National Suicide Research Foundation 1 Perrott Avenue College Road Cork T: 021 4277499 F: 021 4277545 E-mail: ella.nsrf@iol.ie

20. 4th Annual Forum Wednesday 2nd September 2009 Royal Hospital Kilmainham “Suicide Prevention – Working Together”

22. 4th Annual Forum Wednesday 2nd September 2009 Royal Hospital Kilmainham “Suicide Prevention – Working Together”

23. The NOSP Forum Royal Hospital, Kilmainham, Dublin. 2nd September, 2009 Organising Nationally: Living Links Michael Egan, Living Links

24. The presentation will look at Living Links - • As a Local Community Response Initiative • Its Purpose & Objectives

25. Living Links was first established in May 2002 in Cloughjordan, Co. Tipperary. • It was established by a small group of local people in direct response to a suicide in the community. • This suicide death was tragic and devastating for people in the community. • There was a huge sense of inadequacy on how to respond and to provide appropriate community support and a consequent sense of failure as a community.

26. Declared Purpose & Objectives: • To provide a voluntary listening, support and outreach service to those bereaved by suicide • To increase awareness and understanding of suicide and its effects on individuals, families and communities

27. To liaise and provide families with information on relevant health services available in their own communities and in the region, and the referral pathways to such services should professional advice and support be required. • To provide practical help, advice and support to the bereaved and to have this help immediately available to people in their own communities.

28. To provide and facilitate a group healing programme, on a needs basis, for the suicide bereaved • To encourage the suicide bereaved and/or suicide affected to establish and foster an ongoing support group among themselves

29. To liaise and exchange information with similar support groups nationally and internationally • To support and encourage relevant research • To produce leaflets and associated literature to be provided to survivors

30. When invited, the outreach worker can provide information and practical support on the following: The funeral The inquest Entitlements What to say to children How to deal with the neighbours Help the person to clarify their personal grief

31. Connect the person to other support services in their area Provide information on suicide and attempted suicide Be there, as a friend, for the person.

32. Establishing a Living Links Committee? • First Steps • Form Local Committee (6 members) • Select a Co-ordinator • Select volunteers for training (25 – 30 max) • Decide Training Venue & Dates (3 days) • Volunteers must participate in the Living Links training Programme • Form a Panel of Volunteers (Interview)

33. ASIST Training (Applied Suicide Intervention Skills Training) Maintain an up to date register of trained volunteers Insurance – Professional Indemnity/Public Liability Telephone Line - Access Recording of Contacts by Co-ordinator Supervision for Volunteers Committee & Volunteer Meetings

34. Living Links active in the following counties - Kerry & Clare Tipperary North, Cork East & Limerick Wicklow & Meath Donegal Sligo/Leitrim Midlands – Longford/Westmeath; Laois/Offaly Cavan Roscommon Committees most recently established – West Cork, Strabane, Co. Tyrone, Total of 15 Committees. Committees planned - North Cork, Coleraine, Co. Derry, Mayo, Swords, Co Dublin, East Galway. Training - Blanchardstown, Dublin. 8th, 9th and 11th September, 2009.

35. Tipperary North 087 9693021 Cork East 087 1370792 Meath 046 9021407 Clare 086 0565373 Limerick City & County 087 7998427 Kerry 087 9006300 Galway City & County 067 43999 (Provisional) Wicklow 01 2868413 Donegal 087 9286007 Sligo/Leitrim 086 3999029 Midlands 086 1600641 Roscommon 086 0311888 Cavan 086 0235414

36. National Committee Office - 5 Lower Sarsfield Street, Nenagh, Co. Tipperary. Phone: 067 43999 or 087 4122052 Email: info@livinglinks.ie Web: www.livinglinks.ie Patron: Daniel O’Donnell

37. 4th Annual Forum Wednesday 2nd September 2009 Royal Hospital Kilmainham “Suicide Prevention – Working Together”

38. Suicidal behaviour among people who resided in industrial schools as children:A ‘forgotten’ risk group Ms Martina O’Riordan, Dr Carmel McAuliffe & Dr Ella Arensman National Suicide Research Foundation This study was commissioned by the National Office for Suicide Prevention

39. Timeline of Events • 1868-1969: 105,000 children in industrial schools • 1934: Cussen report • 1970: Kennedy report • 1984: Responsibility for these children transferred from Department of Education to Department of Health…and to foster care • 1999: An Taoiseach’s apology on behalf of the state • 2000: Establishment of Commission to Inquire into Child Abuse • 2002: Establishment of Residential Institutions Redress Board • 2009: Report of the Commission to Inquire into Child Abuse (Source: CICA Report, 2009; Raftery & O’Sullivan, 1999; SI 358, 1983)

40. Objectives • To examine the association between institutional child sexual abuse and suicidal behaviour. • To examine suicide risk and protective factors among people who resided in industrial schools.

41. Methods Phase 1 • I) literature review of institutional child sexual abuse and suicidal behaviour. • II) consultations with survivors of abuse in Irish industrial schools. • III) interviews with frontline staff and directors of specialist support services.

42. Part I: Literature Review • Major Outcomes -There is a lack of studies addressing the relationship between institutional child sexual abuse and suicidal behaviour and related mental health difficulties. -Studies focusing on the consequences of child sexual abuse in general reveal consistent evidence for an association with adult suicidal behaviour, in particular non-fatal, as well as suicidal thoughts (e.g. Ystgaard et al, 2004; Roy, 2004; Esposito & Clum, 2002; Brodsky et al, 2001; Molnar et al, 1998).

43. Part II: Consultation with Survivors Overview 6 group meetings + 4 individual meetings = ca. 90 participants Outcomes • Situation at time of deliberate self-harm or suicidal thoughts • Factors related to the abuse experience • Complaints procedures, inc. Redress Board • Mental and physical health issues • Available support & contact with health professionals

44. Part III: Qualitative Study • Objectives -To investigate referral procedures and treatment approaches provided by the National Counselling Service (NCS). -To obtain information on factors associated with risk of suicidal behaviour as well as protective factors through interviews with health care professionals in the NCS.

45. Risk and Protective Factors for Suicidal Behaviour identified by the Specialist Support Services

46. Phase 2: Case-control Psychological Autopsy Pilot Study • Objectives To compare suicides to a control group of people currently living who resided in institutions as children on the prevalence of mental and physical health problems and negative life events. • Methodology Semi-structured interviews with former residents of institutions and with the families of former residents who have died by suicide. Completion of questionnaires by health care professionals of former residents who have died by suicide.

47. Phase 2 : Pilot Study Sample size: Min. 10 participants in each of the 3 groups (control; family informants; health care professionals)  Min. 30 participants Progress: Control group interviews completed; informant interviews to be completed Data items: Socio-demographic characteristics, traumatic life events, child sexual abuse, psychiatric disorders, self-esteem, use of alcohol and drugs, contact with health care services.

48. Demographic Characteristics:11 Pilot Study Control Participants Gender M:7 F:4 Age 56.6 years (47-75) F:55 (47-58); M:57 (50-75) Marital Status Divorced/Separated:5 Married:4 Education Primary/None:4 Age at entry to Industrial School (mean) 4.5 years (3 months- 12 years) Have children 9

49. Reported abuse among pilot control participants

50. Reported sexual abuse among pilot control participants Age abuse started: 8.9 years (7-11) Age abuse ended: 14 years (9-22) No. with more than 1 perpetrator: 8 Total group Adult perpetrators: 8 Peer perpetrators: 5 Both: 3