Research reportCharacteristics of deaths by suicide in Northern Ireland from 2005 to 2011 and use of health services prior to death
Introduction
Suicide and suicidal behaviour are recognised as a wide-reaching social and important public health issues with annual rates of 11.8 per 100,000 in the United Kingdom (UK). It is also a major economic concern with combined costs of £1.4 million per suicide in the UK (Knapp et al., 2011). Northern Ireland (NI) is the sole country in the UK to have demonstrated an overall increase in recorded suicides in the last decade (Snowcroft, 2013, Tomlinson, 2012, Northern Ireland Statistics and Research Agency, 2014). However, disparity in coronial reporting suggest unreliability, particularly with regard to those ‘narrative׳ verdicts which are increasingly used in England, Scotland and Wales (Gunnell et al., 2011, Carroll et al., 2012). Such verdicts tend not to be used in NI where there is now a single coroner׳s service thus increasing the consistency of the recording procedures.
Self-harm, suicidal ideation and mental disorders are important precipitating factors for death by suicide. Psychological autopsy studies indicate that over 90% of those who die by suicide have a psychiatric disorder (Foster et al., 1997). NI has a history of conflict, and there is evidence that those who have been exposed to the conflict have a higher risk of mental disorders (Bunting et al., 2013, Ferry et al., 2013). The mental health needs of the NI population are higher than those of other parts of the UK. It is estimated that 24% of women and 17% men in NI have a current mental health disorder, a figure 20% higher than England and Wales (Appleby et al., 2013). Results from the World Mental Health Survey initiative demonstrated that NI consistently ranked in the top three countries with respect to rates of mental disorders, and the NI prevalence of Post-Traumatic Stress Disorder was the highest of all the countries surveyed (Bunting et al., 2013). There is also evidence that people in NI who have experienced conflict related traumatic events are more likely to have suicidal ideation and plans than those with other types of traumas, even when the effects of mental disorders are controlled for (O׳Neill et al., 2014). In addition, school children in NI who have reported having experienced the conflict have higher rates of self-harm (O׳Connor et al., 2014).
In addition to mental disorders, people with physical disorders have an increased risk of self-harm and suicide (Singhal et al., 2014). Health service contact offers an opportunity for the delivery of suicide prevention interventions; however, the inconsistencies in the recording of suicides have resulted in few studies of the patterns of health service use prior to death by suicide. Studies of UK primary care contact prior to suicide demonstrate that certain populations, younger people and females, are more likely to present to their General Practitioner prior to death (Power et al., 1997, Stark et al., 2012). Studies of all health service use has shown that a greater proportion of individuals who die by suicide have contact with primary care providers than with mental health specialists (Luoma et al., 2002). Secondary care service users also continue to contact access primary care services in the period prior to death by suicide (Pearson, et al., 2009). The objective of the current study was to examine the characteristics and service use history of those who died by suicide in NI, as well as mental/physical diagnoses at time of death.
Section snippets
Method
Approval was obtained from the University of Ulster ethical committee to undertake the research. Cases were recorded by year of death and deaths by suicide and undetermined intent were generated by staff from the NI Coroner׳s Service (CSNI) which subsequently directed file selection. The requirements for a coronial verdict of suicide were stricter than those required for classification as a probable suicide and inclusion in the database. Undetermined deaths, which were probable suicides, were
Results
Information was gathered for those cases which occurred between 2005 and 2011 (N=1667). Gender ratios for completed suicides were 3:1, 77% male and 23% female (Table 1). Of these, gender proportions were similar in those under 19 years (9.3% and 7.9% respectively), while males demonstrated somewhat higher rates aged between 20 and 39 years. Female suicides were highest in those aged between 40 and 69 years. These differences did not reach statistical significance.
A higher proportion of females
Discussion
The current research indicates that whilst suicide prevention efforts typically target the young, the average age of the individuals in this population was 40 years and the rates of suicide were highest in those aged 20–50 years. The cohort of people who were most at risk of suicide several decades ago continue to remain at risk as they grow older. In NI, this is the population who witnessed the years of the conflict when violence was at its peak. Several theorists have elucidated an
Limitations
This was the first time that coronial flies were used to assess the characteristics and service use history of those who died by suicide in NI. The findings offer a unique insight into this population and it is important that they inform suicide prevention policies and service delivery. In common with the rest of the UK, the data on suicide in NI are subject to issues of data reliability, most prominent perhaps the delay between death and registration. Also problematic is the issue of
Conclusion
The high levels of mental disorders in NI (Bunting et al., 2013), along with rising suicide rates in recent years (Snowcroft, 2013) and associations between conflict related trauma and suicidal behaviour (O׳Neill et al., 2014), indicate a need for heightened consideration of the ways in which people with mental disorders are identified and treated in NI. Importantly, the mental disorder variable refers to having been identified as having a mental disorder excluding people with an undiagnosed
Conflict of interest
No conflict declared.
Role of funding source
This study was funded by the Northern Ireland Public Health Agency, Research and Development Division (COM/4027/08). The funders had no role in the research or in the preparation of this manuscript for publication.
Acknowledgement
The authors acknowledge the Northern Ireland Coroner׳s Service and senior Coroner Mr John Lecky for their support in providing the data for this study.
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