Wednesday, 10 December 2008
Sub-Committee on the High Level of Suicide in Irish Society DebatePage of 3
Chairman: I welcome Professor Patricia Casey from the Mater Misericordiae Hospital. Before we begin, I wish to draw attention to the fact that while members of the committee have absolute privilege the same privilege does not apply to witnesses appearing before it. Members are reminded of a long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House, or any official by name or in such a way as to make him or her identifiable. I invite Professor Casey to make her presentation.
Professor Patricia Casey: Thank you. It is a great honour to be here and I regard it as a great opportunity to make suggestions to the committee so that we can do something about suicide and deliberate self-harm in an attempt to achieve the goal of reducing both. I had supplied copies of my presentation. The only addition is that the summary has been superseded by a new summary and I have copies of that new summary for members of the committee.
I thought I should briefly explain why I am here and my remit in this area. I am a practising psychiatrist, which is crucial. In trying to ascertain the developments on suicide and deliberate self-harm prevention and intervention on the ground, one needs the input of practising psychiatrists. Even though I am a professor I see and treat patients. I am not hiding in an ivory tower writing papers all the time — although I also write papers. I have published papers in the area of deliberate self-harm, suicidal ideation and depression. I am currently working on a study of suicidality and the connection between seasonality and suicide, the results of which are coming through at the moment.
I do a one in three on-call rota. I see what it is like in the accident and emergency unit in the middle of the night — or at least my junior doctors do and they telephone me. One of those junior doctors is with me today. Therefore I know what is happening on the ground when people present at the accident and emergency unit in a suicidal crisis.
I went through the Reach Out recommendations in some detail. This is the document on which our national strategy for suicide prevention and deliberate self-harm is based. I have huge issues with it. There are 96 guidelines. Any document with 96 guidelines is doomed to failure. I have given examples showing that many of the recommendations are vague, aspirational, unfocused and irrelevant. The one that is both aspirational and also ideal is that on the development of comprehensive multidisciplinary teams throughout the country. That is the ideal. If we could achieve that I have no doubt we would make some inroads into the prevention of suicide. It would not be the whole answer but would help greatly. Most of the recommendations seem to be focused on training. Much is quite bureaucratic. Not very much of it is based on intervention. Of the 96 recommendations, in only three was treatment or intervention mentioned for deliberate self-harm or people who are suicidal. That is a significant lack.
On the positive side, at the very end — it is telling that it was at the end — research was mentioned. The last two recommendations emphasised the importance of research into suicide and deliberate self-harm. We should see much more emphasis on research at this point in our attempt to understand suicide and deliberate self-harm because very little Irish research is going on in this area. The National Suicide Research Foundation has done considerable work on deliberate self-harm, but it is mainly epidemiological research. It is measuring prevalence and risk factors. However, we need more research into different interventions to establish what works and what does not work.
The final recommendation, 26.2, mentions that we need to review the current evidence base from international studies, which I wholeheartedly support. However, that is not enough because we need to know that the interventions we are using in this culture and country are working. Yesterday I read a paper on interventions for deliberate self-harm people in five middle-income countries. That study found that simply going to the accident department and being assessed reduced the prevalence of repetition of self-harm in that group. We know that what works in America and the UK does not work in this country because of different cultures and people having different needs. We need indigenous research in particular on interventions.
When we are dealing with deliberate self-harm in the accident department there are no services to which I can refer somebody who in a crisis self-harms or even repeatedly self-harms. The generic psychiatric services are not equipped to deal with such people who need specialist interventions. They need cognitive therapy, DBT and CAT. St. Vincent’s Hospital, Fairview, to which the Mater Misericordiae Hospital is attached, used to have DBT therapists who were withdrawn. Those people were highly trained psychiatric nurses and had gone abroad to train in dialectical behaviour therapy. They were taken off that duty and sent back to the wards. There is now no service to which I can refer these impulsive people who repeatedly overdose or cut themselves. This allows members of the committee to understand what is happening about the recommendations on the ground. Therapies that should be available and that were available four years ago are no longer available.
The only services available for this group of patients is to assess them in the accident and emergency unit, decide whether they are suicidal and, if they are still actively suicidal, admit them. In terms of interventions for secondary prevention — by that I mean prevention of repetition — there is nothing, which is a major deficiency.
There are several vulnerable groups who need dedicated interventions. There are many homeless mentally ill who self-harm. Many of them have multiple interpersonal problems. Many of them have a history of sexual abuse. Many of them have substance misuse problems. Such people self-harm repeatedly. There are no services for that group. There are no dedicated services that will go out into the hostels to try to establish contact with this very vulnerable group of people.
People with borderline personality disorder are probably those who harm themselves most frequently. No dedicated services are available to assist self-harmers and substance misusers. While substance misuse can be treated, no therapists are available to specifically target the component that is tied in with self-harm. I recently spoke to the chairman of a group that is drawing up nice guidelines for the management of borderline personality disorder in the UK. The paper in which the group’s guidelines will be described is to be published in the British Medical Journal early in the new year. I understand that the UK authorities will propose that dedicated services be provided for borderline patients, dealing specifically with self-harm. Such a system is equally needed in Ireland because those who self-harm are a drain on accident and emergency services and generic services.
It is difficult to engage with such people, who require specialist interventions. The UK National Institute for Health and Clinical Excellence has stated that an explicit, integrated and theoretical approach, which is used by treatment teams and therapists and shared with service users, is needed. The institute is recommending that dedicated therapists, working in tandem with the generic services, be deployed to deal with self-harm. That is the kind of approach we need here. The guidelines I have mentioned are to be issued by the UK National Institute for Health and Clinical Excellence in the new year.
I would like to speak about research into deliberate self-harm, suicide attempts and parasuicide, with specific reference to a proposal I submitted to an overseas group that wanted to give money to UCD to conduct research into self-harm. As it happens, the money in question has dried up because of the recession. My proposal, which I am mentioning in the context of something that should be recommended by everybody interested in the prevention of suicide, is based on a simple principle. It is based on a study, which was published in the British Journal of Psychiatry in July 2007, of people who are regularly in contact with a therapist by means of postcards rather than face-to-face. The study, Postcards from the Edge, may seem incredibly simple. It found that people who are isolated, lonely and disconnected from society felt more connected — their rate of repetition of self-harm was reduced — when they received a postcard every two or three months over a period of a year. Studies of this nature, which are not expensive, should be recommended by this sub-committee and other people who are committed to this issue. We have had a few epidemiological studies in this country — I refer in particular to a study of self-harm published by a group in Cork — but I do not think we have had enough intervention studies. We need to move beyond the reports we already have, which are quite commendable, to look at interventions. I have mentioned the study that is of interest to the sub-committee.
Further studies of suicide, such as psychological autopsies, need to be conducted. The only such study that has been undertaken on this island was done by Dr. Tom Foster in Northern Ireland approximately ten years ago. Psychological autopsies are important because they help us to understand the extent of psychiatric illness and determine whether the suicidality of certain people is being missed when they visit general practitioners or accident and emergency departments. Studies of this nature are needed to give us all that information. In his study, Dr. Foster found that the rate of psychiatric illness among young men who took their own lives was much lower than the rate of such illness among other groups of people who took their own lives. If one is targeting a prevention programme at young men who are deemed to be vulnerable to suicide, one might be wide of the mark if one’s approach is to give them all anti-depressants. We need basic information of this nature to help us to decide how we should target our interventions. At the moment, we are depending on material from other countries. It is possible to bring about the change that is needed in this respect. I understand that a psychological autopsy study was being conducted in the Republic of Ireland, but I do not know if it has been completed or will be completed.
I wish to speak about intervention. We certainly need better psychiatric services. We know from British data, rather than Irish data, that a sizeable proportion of people who take their own lives have been in recent contact with the psychiatric service. The studies I have mentioned are needed to provide additional information. If the British finding I have mentioned — that people who kill themselves are likely to have had contact with the psychological services in the previous month — is borne out in this country, we will need to pinpoint the deficiencies in our services. We accept that there are many deficiencies. Better psychiatric services are needed in the first instance.
Crisis intervention beds are needed in the current financial climate. I am aware of two cases that arose on the same night last weekend. The first involved a senior company executive who had just been given notice that he was being laid off as a consequence of the recession. The second case involved a builder from another country who was being let go. When they came in, one of them was actively suicidal and the other had taken an overdose. I do not think either of them has a mental illness. Neither of them could go home because they were in a state of acute crisis. Acute crisis beds are needed for such people, particularly in the climate we will face over the coming months.
I note that the need to reduce alcohol use was mentioned many times in the report. That is to be commended. The sub-committee should encourage the Government to implement the recommendation in that regard. Evidence from Britain suggests that brief interventions for alcohol misuse in primary care might help to prevent self-harm and suicide. There is a large evidence base to show that the alcohol consumption rate is lower among those who consult their GPs and avail of two or three ten-minute sessions with them, particularly when such intervention is accompanied by the provision of written information.
We need to make fast-track services available to those who are suicidal. I know they are available in Dr. Barry’s area. Those of us who work in the Mater Hospital are quite lucky because there is an accident and emergency department at the hospital. When a GP telephones us to make an appointment for somebody who is suicidal, we cannot offer an urgent appointment in the clinic but we can suggest that the person be referred to the accident and emergency department, where they will be seen by the junior doctor on call on the same day. As a consequence, 35% of our referrals from accident and emergency departments relate to people who are presenting in a suicidal crisis. Some kind of fast-track service should be offered to units that do not have ready access to an accident and emergency department. That would be welcome.
We need to reconsider carefully the media guidelines on suicide. It is often talked about too much. I do not want people to think I am trying to deny that it is a reality. If suicide is talked about and written about too much, it can almost become seen as just another normal lifestyle option. We have to be careful when drawing up media guidelines.
I will conclude by summarising my recommendations for suicide prevention. The document under discussion, which contains 96 recommendations, is far too broad. A scattergun approach is being adopted in the hope that by focusing on everything, one will help someone somewhere. Much of the focus of the document is administrative rather than clinical. There has to be a clear distinction between primary and secondary prevention. Secondary prevention involves intervening to prevent the repetition of self-harm. The document should focus on achievable targets as many of its targets are unachievable. For example, I was struck by the recommendation on including sport and leisure facilities in county development plans. I have no idea what is the evidence base for making such a recommendation. While it is a great idea on a human level, I do not believe there is an evidence base for including it in a suicide prevention document. We must get real.
Time lines are needed for achieving specific targets. The document does not have a timeframe for achieving targets and should specify what can be achieved and when it can be achieved. Certain targets are achievable in the short term, including, for example, some of the research to which I referred and a fast-track service, while others will take a little longer to achieve. Time lines should be written into any future document.
Guidelines should be clear and evidence based. The reason this document makes little reference to interventions is that these are the difficult part. While an evidence base is available, it is limited. I was asked by the Royal College of Psychiatrists to write a module on deliberate self-harm and suicide for its continuing professional development on-line journal. I believe I have brought a copy with me but, if not, I will supply a copy as the document may be of interest to the sub-committee. The module goes through all the interventions which have been examined and the level of evidence in support of them. Members may find it useful.
We need further research. As I indicated, we need psychological autopsy studies, diagnostic studies for deliberate self-harm, etc. I firmly and wholeheartedly support the establishment of a confidential inquiry into suicides, similar to that in place in Britain. This is essential. It is also achievable and would provide much of the information we are lacking, particularly regarding the role of the psychiatric services, whether they are remiss and the level of contact which has taken place with psychiatric services and general practitioners before a suicide. This is basic information which we lack and a confidential inquiry is a priority.
Ideally, we should try to cross reference, by having a record linkage system between the self-harm register and hospital records. A similar system is in place in the Scandinavian countries. Although ethical issues may arise in this respect, we should aim to establish such a system. I apologise if I have run over time.
Chairman: What progress has been made on this issue? We receive mixed messages from the system in this regard. For example, when we ask a question of the Minister or Professor Drumm, they refer to the appointment of psychiatrists and so forth. I also ask Professor Casey to address the likelihood of increased suicide ideation and psychiatric illness as a result of the recession.
Senator Phil Prendergast: I thank Professor Casey for her interesting presentation. A review of psychiatric services is under way. I am concerned about the lack of adolescent psychiatric beds, although I accept the number of beds may not be the key issue. In terms of the assistance provided to those who present to psychiatric services, I do not believe it is possible to help adolescents if they are placed in a unit which is not appropriate to their specific needs. Should staff in psychiatric units upskill to deal with this issue? Would it be useful to introduce a pilot programme which would test some of Professor Casey’s recommendations? The programme could be reviewed.
Professor Casey indicated that profile data for other countries may not be relevant to Ireland given the mindset here. Are measures used in other countries relevant to Ireland when an evaluation is made of an issue of this magnitude?
Individuals with a substance abuse problem often suffer effects which require them to be admitted to a psychiatric unit, either to come up or come back down, as it were. I am not certain what term is used. Should such people be managed differently?
We have debated the need to discuss suicide in a manner which recognises the problem without frightening young people. I am from Clonmel, a large urban centre. A report done a couple of years ago showed a high number of young people in the area were affected by mental health problems. I visit a number of schools as part of my work on a sexual health programme. In some cases, I ask whether anyone needs to discuss further any of the issues I raise. In such circumstances, I refer the person to someone in the school to whom they can talk. The issue of referral is important. Through my clinics I have learned of cases of young people who urgently require a psychiatric bed and need to be constantly observed by professionals or their parents. I become disillusioned — I do not use the word lightly — when I hear about reports published in 1965 and 1984. I may be new to this issue but it is 2008 and the number of suicides is increasing. I do not wish to apportion blame but it is horrific that we are not making progress on this major area of concern.
Professor Patricia Casey: The Chairman asked about what is happening on the ground with regard to multidisciplinary teams. Without wishing to be facetious or smart, I will be able to answer his question in about six months if he can wait that long. One of my lecturers is starting a research project on this issue and will write to every psychiatrist in the country to find out who is on his or her multidisciplinary team.
Having spoken to many colleagues around the country, I am aware that some psychiatrists do not have access to a clinical psychologist. While consultant psychiatrists can do a limited amount for the large number of people who need psychological interventions, we also need clinical psychologists. In addition to having no access to clinical psychologists, some of them do not have nurse therapists, occupational therapists or social workers in their teams. I believe and hope that every psychiatrist has a community nurse as I understand community nurses are present in all the multidisciplinary teams. We are doing a project on this issue and, if the Chairman wishes, I will report to the sub-committee in due course.
All the international evidence shows that suicide rates increase during times of recession and there is no doubt deliberate self-harm rates increase during recession. We can, therefore, expect an increase in the suicide rate, which has been in decline. I have no doubt deliberate self-harm rates will escalate. There is scientific evidence and literature on that from other countries.
Beds for adolescents will open soon in the grounds of St. Vincent’s Psychiatric Hospital in Fairview. I was notified about this last week. I do not know what is happening around the rest of the country. There is a shortage of beds for adolescents. On occasion, maybe twice or three times a year, we have to admit adolescents to adult units.
On no account should adolescents be admitted to adult psychiatric units. Their needs are very different. It can be a frightening place for an adolescent who is in turmoil to be with adults who may be acutely disturbed in a different way. All international bodies, including the Royal College of Psychiatrists, recommend that adolescents have their own dedicated nurses. Even the skills-mix of nurses in an adult psychiatric ward can be very different. One cannot mix the skills. People have to qualify and specialise in one area. It would be like asking a child psychiatrist to become an adult psychiatrist. It simply does not work.
There are problems with using measures and data from other countries. The difficulty is that is all we have for interventions. That is why, as the Senator suggested, piloting some of these simple interventions is important. While they cannot be done for nothing, they can be done relatively cheaply. It is all we have to rely on currently.
People who misuse alcohol can be quite easily managed within general adult units because their stay is short, maybe a week for detoxification. It is afterwards that the work needs to be done. This happens with dedicated alcohol services. I can only speak for Dublin, but the services are good. Alcoholics Anonymous, the Stanhope Centre and St. Vincent’s, Fairview, have good substance misuse programmes. Substance misusers who repeatedly self-harm are the problem. Cocaine and opiate misusers who repeatedly self-harm are a demanding group who require specialist services.
There is no good evidence that having suicide awareness in programmes in schools is positive. In fact, they may harmful. Some studies by David Shaffer in the US have shown this. Young people tend to be aware of suicide and the warning signs. These studies recommend that instead of talking to students there should be confidential screening for young people who are disturbed.
In America, however, this is what parents did not want, surprisingly. They were not keen on the screening programmes, instead wanting suicide awareness programmes. They are easier to deliver and less challenging for parents. If a person comes through a screening needing further assessment, it may make parents feel guilty or troubled. In preventing suicide and self-harm, screening is more preferable and has been shown to be more effective than simply talking to a group about suicide.
The committee referred to the concern of over-talking suicide. It is a great concern. We must be careful about how we talk about suicide. On the one hand, we may upset families bereaved by suicide and on the other, we might glamorise it for youngsters. Trying to tread that middle ground and find a language that does not upset distress, stigmatise or accuse families is difficult. I hope the press do not misquote me on this one but we need to stigmatise the act, not the person who has committed the act. It will be difficult to achieve this.
Chairman: The Irish Association of Suicidology and the Samaritans’ guidelines suggest the media should ask the questions, “Will this more likely cause someone to seek help?” and “Will it hurt the bereaved?”
Professor Patricia Casey: Any person presenting in such circumstances is first seen by the medical team in the accident and emergency department. They will be treated surgically or medically first. They are then seen by the duty registrar in psychiatry who is on call. They have a full psychiatric and psycho-social assessment. Pending that assessment, the duty consultant may be telephoned and the patient’s case discussed.
We would be contacted if there is a concern or doubt about whether the person should be admitted or if the doctor wants the patient admitted but the patient refuses. We would also be contacted if there is a doubt about whether the person is still suicidal. In about a third of cases we would be contacted on the night of admission.
There is also a fail-safe system whereby all the deliberate self-harm patients are discussed in a cold round with the consultant and liaison psychiatry the following day. Some of the cases could have just been down to, say, a row with a boyfriend with no underlying psychopathology issues. In such cases the junior doctor may have made a decision to send the person home or refer her to her GP. However, it will still be discussed at the cold round the following day. Everything gets discussed with a consultant within a short time.
I find it contradictory that while sport is good for the mind and the body, it is sponsored by alcohol companies such as in the Heineken rugby cup and Guinness hurling championship. We must stop this association of sport and alcohol. There are also pop concerts promoted by alcohol companies. We are in a bind, where we try to entice them into playing sport yet we then push drink on them. There is a complete contradiction in that. We will have to ban all alcohol sponsorship of sports.
Professor Casey mentioned the issue of talking about it too much. Last year, I published a document on what we can do about suicide in the new Ireland. I came across schools that did projects on bullying. They seem to be very effective in the schools, harnessing the young people, dealing with the issue of bullying in schools and speaking out about what it does to the self-esteem of young people. From my experience studying this as a lay person for the last 18 months, I feel that in 20 years we will look back at this era and say we were savage in our attitude to mental illness. It should be treated in the same way a broken leg is treated. People are ashamed to say that they suffer from mental illness. We do not have enough role models who have been able to continue with their lives. J.K. Rowling came out and said she was suicidal because of personal circumstances. We have a long way to go to address the stigma of mental illness. Young people should get help if they are depressed.
I am a big fan of the National Suicide Research Foundation. I worked with Dr. Ella Arensman, and I find her absolutely fantastic. She did a survey on what was the most upsetting issue for 17 to 19 year olds in schools. The most stressful area was homework. Who did they turn to when they were stressed? Their first choice was their friends. Interestingly, teachers were way down the line. The survey showed that 9.1% of the 4,500 young people surveyed in the south east were continuously harming themselves. I find it a contradiction that homework is the number one issue to drive them to self harm, but that only 10% of them turned to teachers for help.
Mental illness has been covered up for too long. Nobody knows the time when any of us will have to deal with such a crisis and we may need help. The stigma has to be lanced. People are not diminished if they have to get psychiatric help or counselling. If they get the right help, they can continue with their lives.
Professor Patricia Casey: The Deputy is correct in her observation about alcohol, sport and concerts. The link between these recreations and alcohol must be severed. It is very interesting to listen to advertisements on radio. I heard one the other day from the Road Safety Authority that encouraged people to drive safely and not to drink and drive. The next advertisement on the radio encouraged people to go down to the nearest pub for the craic. I agree fully that the link must be severed.
The rest of the Deputy’s question was about the stigma of mental illness. I believe that the stigma is much less than it was, but there is still a long way to go. I go around the country giving talks on depression, suicide, schizophrenia and stress. I could go to a village in rural Ireland and 200 people will show up, asking questions openly. The problem with stigma arises with people being open about it outside of their own family and communities. People are often reluctant to tell their employers that they have a mental illness, due to what might happen. A survey was conducted here about two years ago which found that one third of those surveyed believed that people with mental illness should not be in the Government.
Professor Patricia Casey: We need only look to Norway, where the then Prime Minister, suffering from depression about ten years ago, addressed the nation about his illness and took leave for six months. He got a “locum” prime minister in to do his job while he received treatment and got better——
Senator Mary M. White: I understand why Professor Casey feels the stigma issue has improved from her perspective, but from my work on the ground, I still believe there is a major stigma associated with mental illness.
Chairman: I think we have to accept that. There is quite a long way to go. I have some questions before we finish. Can Professor Casey deal with the suicide statistics that are bandied about? Can she outline what are the resources allocated to suicide prevention through the National Suicide Prevention Office? There was much debate in the Dáil when the then Minister of State for mental health issues, former Deputy Tim O’Malley, refused to set targets for suicide prevention. How does Professor Casey feel targets should be approached?
Section 12 of Reach Out deals with deliberate self harm. How has Reach Out tackled deliberate self harm in the three years of its existence? How has the State responded to this? Where does Professor Casey feel that crisis intervention beds should be located? Should they be located in general, mental or psychiatric hospitals?
Professor Patricia Casey: I am no more privy to the suicide data than anybody else. It has been suggested that we are underestimating our suicide rates, but I do not know if that is true or not. We need to be careful about making statements without some evidence to back it up. I have an interest in the area of single vehicle car accidents. It was mentioned in the document we have here that there may be an underestimate of those deaths. We are currently doing a study, but because we were doing it without funding, my lecturer undertook to do it with the assistance of Professor Denis Cusack, the coroner for Kildare, Dr. O’Farrell and Dr. Geraghty, who are the coroners for Dún Laoghaire and for Dublin, respectively. We got access to their coroner’s inquests, including the forensic evidence given by the Garda Síochána.
We examined whether some of these deaths in single car accidents were caused by suicidal intent. We identified three suicides out of the entire 156 for the years we covered but two of those three were already identified by the coroners as suicide and went into the suicide statistics, so only one was identified by us alone. If we had the money, we would like to extend that study to the rest of the country and visit coroners throughout the country, with their agreement, to examine their files. However, we do not even have the money to buy the train tickets. That is the problem.
I cannot comment on the funding because I am not an economist. All I know is that if much money is being put into it, I do not see it on the ground in the Mater Hospital and I am sure my colleagues do not either.
Professor Patricia Casey: Targets are essential. When one has 96 stated objectives, without targets there is a danger we will go around in circles like headless chickens. There should be targets and we should clearly focus on what is achievable and in what time it is achievable. We should forget about the recommendations that are impossible unless we have utopia in Ireland, and given that we did not have utopia during the boom, we will not have it now during the bust. We need to go back to the drawing board and sift through the 96 targets, consider those that are achievable and set timeframes by which they can be achieved.
They can be achieved. For example, the fast tracking system can be set up throughout the country without too much difficulty. The evaluation of the level of assessment for self harm around the hospital, as Senator Mary White suggested, can be done very rapidly. We must have targets or we will just flounder around forever.
Professor Patricia Casey: To be honest, I have seen no evidence they have done anything about it. Nothing has changed on the ground for me or for most of my colleagues. The nurses who were trained in deliberate self harm and dialectical behaviour therapy, DBT, which is one of the only interventions that has been shown to work — members will have seen the handout I mailed to them this morning — were withdrawn and taken back onto the wards. I am not convinced the HSE has any idea what it is doing about this.
Professor Patricia Casey: There are not many psychiatric hospitals in which crisis beds could be put any longer because most of them have closed, thankfully. People would not go into the psychiatric hospitals in the first place. All we need are one or two beds either attached to a psychiatric unit in a general hospital or perhaps linked in with some of the other outreach services that exist.
Senator Phil Prendergast: Would it be feasible to have a pilot programme in some area where those specialist therapists were put back on stream to do the job they are trained to do? That could have a measuring ability and would be a help because they would be focused and direct. This would not be aspirational or something we merely should do. It is something we could do.
Professor Patricia Casey: Senator Prendergast is absolutely correct. There is even a simpler study we could do. A study was conducted in the UK, the POPMACT study, which was published in 1998 with a follow-on study in 2002, in which deliberate self harmers were given the option of getting a self help manual, with assistance from a therapist if they wanted it. That not only reduced the number of self harm episodes but it is the only intervention that has been shown to reduce the suicide rate when they followed it up.
Professor Patricia Casey: On a personal basis, I would like to thank Deputy Neville because he has done more to highlight the suicide and deliberate self harm issue than any other Deputy in the House. We are eternally grateful to him for that.
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