By Lesley-Ann Black & Keara McKay
Suicide is a major public health issue which devastates families and communities. The circumstances that may lead a person to take their own life are complex and unique. Ascertaining why a person may end their life through suicide is still poorly understood.
Thoughts of suicide or suicidal behaviour may be triggered by a single event or a series of events over time. Risk factors, such as self-harm and mental illness (treated or untreated) are also linked to suicidal behaviour. Suicide can also be related to a complex interplay of life problems of a personal, social or economic nature which can lead to feelings of hopelessness and despair, such as:
|Drug / alcohol misuse|
|Family history of suicide|
|Trauma or abuse|
|Poor social conditions or homelessness|
|A previous suicide attempt|
|Chronic disease or disability|
There are many challenges regarding the mental health and wellbeing of the local population, not least that Northern Ireland is a post conflict society. People here experience 20-25% higher levels of mental health illness when compared to the rest of the UK, and around 1 in 5 adults are reported to have a diagnosable mental health condition at any given time. There are significantly higher levels of depression than in the rest of the UK, higher antidepressant prescription rates, and higher incidences of self-harm. Northern Ireland also has the highest rate of suicide in the UK. These are all indictors of poor mental health.
The proportion of spend on mental health remains the lowest in the UK; estimated at around 8% of the total healthcare budget, despite the evidence of the substantial levels of need. Overall expenditure on mental health in Northern Ireland remains unknown, as mental health funding is allocated across different programmes of care and the Health and Social Care Board.
The Northern Ireland Statistics and Research Agency produces statistical data on suicide deaths. This blog post includes the most recent published annual figures (to 2017).
Suicides are officially recorded according to a UK-wide definition. This includes deaths from Self-inflicted Injury as well as Events of Undetermined Intent. The definitions are linked to a series of standardised International Statistical Classification of Diseases codes (ICD10) which are used for tabulating cause-of-death mortality statistics.
However, care should be taken when interpreting suicide data. Firstly, suicide rates are likely to be higher than reported data because anomalies and underreporting in the classification of suicide deaths exist. Secondly, the registration of a death can be delayed where accidental, unexpected or suspicious circumstances arise. Suspected suicide deaths are likely to be investigated by the Coroners Service for Northern Ireland. This can result in a delay from when the death occurred to when it is officially registered – which may not be in the same year. Although the centralisation of Northern Ireland’s Coroners Service in 2006 has reduced delays, registration can still take many months. For example, the average time taken to register a death by suicide was 328 days in 2006 and 155 days in 2017.
Significant differences also exist in the coronial, inquest and registration processes in how suicide data is collected and interpreted across the UK. Despite this, Northern Ireland is reported to have the highest age standardised suicide rate per 100,000 population compared to other UK jurisdictions (Table 1). In 2017, Northern Ireland had a rate of 18.5 per 100,000 people, whereas England’s rate was half that, at 9.2 per 100,000 people.
|Jurisdiction||Rate per 100,000 in 2017|
|England||9.2 per 100,000|
|Wales||13.2 per 100,000|
|Scotland||13.9 per 100,000|
|Northern Ireland||18.5 per 100,000|
Table 1: Age standardised suicide rate per 100,000 in UK jurisdictions
Northern Ireland: Statistics by year
Between 2000 and 2017, a total of 4,476 deaths were registered as suicide in Northern Ireland (Figure 1). In 2000, 185 deaths by suicide were registered. By 2005, the number rose to 213. In 2017, the number of registered deaths from suicide was 305. This trend is unlike the rest of the UK where suicide rates are falling.
Several explanations for the upward trend in local suicide deaths has been offered including: changes in the Coroner and reporting process; use of mental health services; rising drug and alcohol misuse; changes in family life and normative expectations; the recession, unemployment, and the legacy of the conflict.
Figure 2 provides the number of deaths by suicide by gender between 2000 and 2017. In that timeframe death by suicide increased substantially, 58% for females and 67% for males respectively.
Although females are more likely to self-harm and attempt suicide, men are three times more likely to die by suicide. Studies have been conducted to ascertain the increased risk of male suicide and why they are such a hard-to-reach group. Reasons may include the perceived stigma attached to discussing mental health problems and a reluctance to seek support, higher rates of substance misuse, impulsivity and access to more lethal methods of suicide, as well as ‘at risk’ groups (gay, transgender, ethnic minorities, farmers, unemployed, rurally isolated, and divorced or separated males).
Suicide rates also vary by geographical area. Two-thirds of the local population live in urban areas, where suicides are more likely to occur (Figure 3). However, importantly, these populations can differ in a number of ways, for example in terms of attitudes, community cohesion, mental health status, and accessibility to services and facilities.
Map 1 shows the average rate of suicide per 100,000 persons by parliamentary constituency over a five-year timeframe between 2012 and 2016.
The constituencies with the highest average annual suicide rates over the five-year period are:
- Belfast North (29 per 100,000);
- Belfast West (26 per 100,000) and
- Fermanagh and South Tyrone (19 per 100,000).
Both Belfast North and Belfast West are small urban geographical areas with dense populations, whereas Fermanagh and South Tyrone is a much larger geographical area, with a slightly larger and more rural population.
At ward level, Map 2 shows higher incidents of suicide are depicted in yellow, orange and red colours, while blue colours illustrate lower rates of suicide. Several hotspots exist, linked to urban areas across Northern Ireland, with Belfast having the highest rates. Clusters of suicide incidences occur within deprived areas. Between 2003-2017 three wards in Belfast had more than 40 deaths by suicide reported (Waterworks, Shaftesbury and New Lodge); the Super Output Areas within these wards are ranked within the top 20% most deprived in Northern Ireland. 24 wards reported at least 20 or more suicides, all of which were located in urban areas. Ten wards had no registered suicides in the timeframe, but all other wards had at least one suicide reported.
There is still a lack of understanding as to why there is such a difference between urban-rural suicide rates in Northern Ireland. Part of the reason may stem from deprivation. Life expectancy and health outcomes for people in deprived areas are significantly less than more affluent areas, and the suicide rate is around 70% higher in deprived areas than non-deprived areas.
In men under 50, suicide is the leading cause of death in the UK. The highest number of deaths by suicide in Northern Ireland in 2017 occurred in the 35-44 age group for males and the 25-34 age group for females.
Suicide is also affecting more young people – rates in the under 18s are disproportionately higher here compared to the rest of the UK. Stressors are linked to academic performance, body image, peer pressure, and social media to name but a few. Furthermore, a National Inquiry revealed a significantly higher percentage of young people who died by suicide from Northern Ireland had a history of alcohol / drug misuse when compared to England, Scotland or Wales.
Suicide Strategies: developments
According to the Department of Health (DoH), suicide and mental health remain key policy priorities. Whilst difficult to predict, with appropriate support, it has been suggested that many suicides are preventable.
A timeline of suicide prevention strategies from the DoH in Northern Ireland are shown below.
|Timeline strategy / plan name|
|2006-2011||Protect Life 1: Northern Ireland Suicide Prevention Strategy and Action Plan|
|2012||Evaluation of NI Protect Life 1 Strategy and Action Plan|
|2012-2014||Refreshed Protect Life: A shared vision. The Northern Ireland Suicide Prevention Strategy|
|2012-2014||Refreshed Protect Life: Action Plan|
|2016||Protect Life 2: A draft strategy for suicide prevention in the north of Ireland.|
Table 1: Age standardised suicide rate per 100,000 in UK jurisdictions
In 2006 the first suicide strategy, Protect Life 1 was published. Its aim was to reduce the suicide rate in Northern Ireland. An overall target to reduce suicides by 15% by 2011 was set. This was not achieved.
The strategy also contained eight objectives and 62 actions to be delivered with involvement from government departments and agencies. Actions focussed on themes such as self-harm, communities, children, media and coroner reporting.
In 2012, accountancy firm Moore Stephens evaluated the strategy. It concluded that progress and examples of good work had been made in some areas. Nevertheless, much more work was required. 18 recommendations were also made, including:
- better governance and accountability for oversight and delivery of the strategy;
- ongoing involvement and support for community and voluntary sectors and greater involvement of Government Departments;
- development of a robust monitoring and evaluation framework;
- more effective tracking of resources.
The evaluation reported that progress against the 62 actions was variable. A number of issues were highlighted – some actions were difficult to measure and those requiring cross departmental or interagency working experienced the least progress. The evaluation noted that the Refreshed Protect Life Strategy (2012-2014) would see a reduction in the number of actions to 50, and 10 new actions added into an Action Plan. However, the authors suggested there were still too many actions, and that these should be reduced and reclassified to afford greater focus.
The Refreshed Protect Life Strategy (A Shared Vision) was published in 2012. Although a reduction in the suicide rate remained the main goal, a new aim, ‘to reduce the differential in the suicide rate between deprived and non-deprived areas’ was added. The strategy also included six measurable objectives and four further longer term objectives with success indicators for monitoring purposes. The strategy highlighted that progress had been made in several areas such as: the establishment of the Lifeline 24/7 crisis response helpline, awareness-raising public information campaigns, training programmes, and the development of community-based suicide prevention initiatives. But it also acknowledged that more needed to be done to tackle suicide.
Alongside the refreshed strategy, a refreshed Action Plan (2012-2014) was published which included a red, amber and green (RAG) status report of progress on the actions. These are summarised as:
Although the strategy was extended to 2014 (and remains in place to date), DoH has confirmed no updated progress on the actions has been published. Therefore, it is not possible to accurately assess the refreshed strategy’s more recent impact or effectiveness.
In 2016, a new draft strategy was developed called Protect Life 2. It highlights many initiatives that are ongoing in terms of prevention, and contains ten objectives, again linked to high level actions. Details of how the actions will be delivered have yet to be published.
Public consultation on the draft strategy called for governance arrangements to be strengthened and specific, measureable actions set. Recent correspondence with the DoH reiterates that work on suicide prevention initiatives are ongoing, and that it intends to establish a new Strategy Steering Group and publish an annual report assessing the implementation of the strategy. Nevertheless, to date, the draft suicide prevention strategy for Northern Ireland has not been implemented given the absence of Ministerial approval and a functioning Executive.