National academic response to COVID-19-related suicide prevention

We have extended our national suicide prevention support role to include responding to local area’s concerns specific to the pandemic. We will be:

  • providing local areas with quality-assured publications regarding COVID-19 and mental health/suicide prevention;
  • discussing challenges and providing advice on suicide prevention concerns via email contact and virtual interactive webinars;
  • facilitating shared learning by linking mental health providers/local areas together.

We have also re-established NCISH data collection via early reporting to an anonymised online questionnaire. This is designed to collect real-time data from clinicians on patient suicide deaths during the COVID-19 pandemic. If you are a clinician working in secondary mental health services in England the questionnaire can be accessed here.

Suicide in England since the COVID-19 pandemic

We have worked with several local areas in England to count suicide deaths for the months before and after lockdown. These are probable suicides as they have not been confirmed by inquest, which means they give us a more immediate picture of any change. We found no rise in suicide after lockdown. However, we need to be cautious about this finding as there could be higher figures in some areas or in some groups and because it is too early to examine the long term impact of the pandemic on mental health and suicide.

Download icon      Download the report here (PDF) 

Evidence and guidance around COVID-19 and suicide prevention

Currently, there is little evidence specific to COVID-19 and suicide prevention. Here, we have drawn together what is available and have collated and grouped it into themes reflecting the concerns raised during our webinars. We will add to this evidence as we become aware of it.

Bereavement support

Bereavement support resources have been adapted to offer advice specific to physical distancing and lockdown restrictions. Information about practical arrangements in addition to available financial and bereavement support:

The NHS telephone bereavement helpline is open daily and is staffed by nurses:

The National Bereavement Partnership also has a helpline and webchat for anyone seeking support, practical advice and information:

Advice from bereavement charities for people who have been bereaved during the pandemic:

A guide to support those who have been bereaved or affected by suicide:

Information about support services for people who have been affected by suicide during the lockdown:

Information is provided for managers running bereavement services:

How mental health services have adapted in response to COVID-19

Following the implementation of physical distancing measures, mental health service providers have had to adapt to delivering care remotely.

COVID-19 has been associated with a system-wide drop in the use of mental health services, with some subsequent return in activity, in this study of referrals and presentations to a provider of mental health and community health service in the UK:

A WHO survey of 130 countries worldwide reports 93% have had their critical mental health services disrupted or halted by the COVID-19 pandemic. Many (70%) countries have adapted their services to overcome disruptions but there are significant disparities:

A survey examining UK mental health staff’s views of the impact of the pandemic on mental health care and mental health service users suggests directions for service development:

Healthcare workers report a change in mindset regarding technology that may become permanent:

A briefing provides key information on the impact of COVID-19 on mental health trusts, including how they have responded to the challenges faced:

A position paper describes how mental health care delivery has been adapted to the demands of COVID-19:

A learning resource for healthcare staff who work with people who may be distressed or suicidal:

A report describing how Emergency Department care for people who have self-harmed has adapted:

Guidance is available for video and phone consultations, including practical issues around ensuring patient engagement, conducting risk assessments remotely, patient consent, and staff training and support:

Guidance for people requiring mental health care

People who are experiencing a mental health crisis are recommended to seek immediate help, irrespective of pandemic-related changes to services:

Guidance on providing remote care

Staff training and support

A competence framework and training for applied psychologists to equip them for digital practice is currently being developed by the BPS DCP Digital Healthcare Sub-Committee.

Suicide prevention training is available to anyone, including NHS volunteers:

There is limited robust evidence for suicide prevention within nursing homes, although gatekeeper training for staff and peer support could be effective:

High risk groups

There is guidance available to support specific sub-groups thought to be more at risk during the pandemic.

COVID-related risk factors also include financial issues, domestic violence, isolation and increased alcohol consumption. Public health responses are needed to help mitigate suicide risk associated with the pandemic (see Suicide risk and prevention during the COVID-19 pandemic (The Lancet)).

Early studies of population mental health from before the COVID-19 pandemic and into the subsequent lockdown period found an increase in mental distress in the UK, particularly in young people, women and those with preschool aged children (see Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population (The Lancet Psychiatry)

Guidance about prisoners

Measures to decrease the consequences of COVID-19 to mental health in offender populations:

GPs can assist in risk reduction generally by improving treatment of depression and recognising risks associated with domestic violence:

Guidance for people who gamble

What impact has the COVID-19 pandemic had on women’s mental well-being?

The COVID-19 pandemic has negatively impacted mental well-being, particularly among women:

Females, young people, those from socially disadvantaged backgrounds and with pre-existing mental health problems reported worse mental health outcomes in the initial phase of the COVID-19 pandemic:

What impact has the COVID-19 pandemic had on LGBT communities?

The LGBT Foundation have published a report on the impact of the COVID-19 pandemic on LGBT communities. The report details findings from an online survey, existing research on LGBT health inequalities and unpublished service user data:

Information about mental health support is provided for people who are lesbian, gay, bisexual, trans, intersex, queer or questioning (LGBTIQ+):

Resources from LGBT-inclusive organisations and support services for those who are experiencing mental health problems or need practical support:

 

Changes in modes of access for help

Although there are no published data available yet, there appears to have been a change in how individuals are accessing mental health support for self-harm and suicidal ideation during the pandemic.

How has service access changed?

Data on incidents of self-harm where COVID-19 stressors have played a role are currently being collated by some self-harm registers but are, as yet, unpublished.

However, A&E frontline workers have anecdotally reported a reduction in self-harm attendance to A&E. Although A&E presentations for self-harm may have decreased, self-harm in itself may not have reduced.

People who self-harm may not be seeking help or may be receiving support from elsewhere, because of perceptions of burdensomeness, stigma, or fear of contracting COVID-19 in a hospital or GP setting:

In contrast, there are reports of an increase in mental health presentations and expression of suicidal ideation in the community through police callouts and crisis helplines, as individuals turn to remote support where social support is currently unavailable.

Guidance about accessing mental health services

People who are experiencing a mental health crisis are recommended to seek immediate help, irrespective of pandemic-related changes to services:

For people already under the care of mental health teams, the NHS reiterates that this support will still be available, but may be via remote methods:

Guidance for people who may want to harm themselves or are concerned about someone who may be thinking of hurting themselves:

The NICE guidance for self-harm and suicide should continue to be followed during the pandemic:

Utilising digital evidence-based interventions targeting suicidal ideation can help individuals when access to health services are limited:

Pandemic-related stressors and suicide prevention

It is important to remember that many of the key priorities for suicide prevention remain during this pandemic (see Preventing suicide in England: Fourth progress report of the cross-government outcomes strategy to save lives (PDF)).

These include:

  • reducing risk in men;
  • preventing and responding to self-harm;
  • mental health of children and young people;
  • treatment of depression in primary care;
  • acute mental health care;
  • tackling high-frequency locations;
  • reducing isolation;
  • bereavement support.

In addition, economic and psychosocial pandemic-related stressors should be addressed for effective suicide prevention during the COVID-19 pandemic. There may also be some protective factors during the lockdown.

The impact of the pandemic on risk and protective factors for suicide has been summarised including recommendations for suicide prevention:

Economic stressors

There is evidence that suicide rates increased post-recession globally and across England, and more so in men and in countries and regions with greater job losses:

Sustained welfare spending, spending on active labour market programmes and high levels of social capital were found to reduce the risk of suicide during a recession:

Psychosocial stressors

Previous epidemics are associated with an increased risk of suicide-related outcomes, particularly in older women, individuals with more severe illnesses and those dependent on others:

The SARS epidemic was associated with a higher number of suicides in females aged over 65:

Prevention and intervention strategies should focus on the mental health of vulnerable groups such as the elderly, who may experience higher levels of fear about the disease, with self-isolation potentially increasing mental distress and loneliness:

How to address mental health and psychosocial aspects of the COVID-19 pandemic in general and specifically for vulnerable groups:

A recent rapid review of the psychological impact of quarantine found negative psychological outcomes may be long lasting, and recommendations to mitigate these outcomes are provided:

Protective factors that have arisen from lockdown

There has been limited research into protective factors from the lockdown.

Anecdotally, these could include:

  • reduction in usual life pressures (school attendance, work issues, peer relationships);
  • increased social connection;
  • a greater awareness of supporting each other’s mental health.
Mental health in the community

Guidance is available on how to support mental wellbeing during the COVID-19 pandemic. Suicide prevention training can help with increasing confidence to ask questions about suicide and responding in a helpful way. 

A Public Health England report draws on real time data and evidence to examine the mental health and wellbeing of the population in England during the pandemic:

Recommended guidance on wellbeing and COVID-19

There is a wealth of information and practical advice available on looking after your mental and physical wellbeing during the COVID-19 outbreak. Here we provide a small selection of that advice.

Guidance for individuals with mental health issues:

Information on how to support people’s wellbeing while self-isolating:

Guidance on maintaining wellbeing at home:

Delivering suicide prevention training remotely

Online suicide awareness training:

E-learning modules on suicide and self-harm for adults working with children and young people:

E-learning tool to help volunteers and health professionals spot early warning signs of suicide:

Training in a group webinar format:

Online resources for supporting people who may be thinking of suicide:

The National Suicide Prevention Alliance’s discussions have generated ideas on how to deliver virtual suicide prevention training:

Occupational concerns and support

What are the concerns about healthcare staff?

Evidence has previously highlighted the increased risk of mental ill-health, self-harm and suicide in healthcare staff. Female health professionals, particularly nurses, are reported to be at an increased risk of suicide:

Anecdotal reports from healthcare professionals suggest there is stigma surrounding disclosing mental health problems, resulting in a reluctance to seek help.

Another barrier to help-seeking among health professionals is the perceived supportiveness of managers:

The COVID-19 pandemic may exacerbate trauma and anxieties in frontline staff:

Beyond the clinical environment, healthcare staff working from home may also be experiencing increased levels of stress and anxiety.

What support is available for healthcare staff?

Providing help at a range of levels is required. Approaches should be flexible and tailored to individual needs.

Free psychological and practical support is available for NHS staff via a helpline, text service and online portal:

Guidance on protecting the psychological needs of healthcare staff:

Support and resources for doctors experiencing mental health issues:

Measures healthcare managers should implement to protect the mental health of their staff:

Four key elements in an evidence-based staff NHS recovery plan:

Guidance to inform managers and team leaders of the psychological and organisational processes to help support staff:

A resource for frontline staff containing advice and tips from a large panel of international experts:

A resource for people working in health and social care in Scotland:

Support for Greater Manchester key health and care workers and their families who have been impacted by COVID-19:

Guidance on working from home

Tips on how people can look after their mental health while working from home:

Ethnicity

Is ethnicity data recorded at death registration?

Data on an individual’s ethnicity is not collected at death registration:

Consequently, our understanding of suicide prevention for Black, Asian and Minority Ethnic (BAME) groups is limited.

Public Health England have reported that BAME groups are more likely to be diagnosed with COVID-19, and death rates for COVID-19 are highest for people from BAME groups:

There is a need for more comprehensive recording of ethnicity data to understand health inequalities. The Office for National Statistics emphasises the complexity of collecting data on ethnicity:

The NHS Race and Health Observatory, a new research centre, is a good step forward, as it will explore the impact of ethnicity on an individual’s health:

What mental health issues are found in BAME groups?

The reported frequency of self-harm and thoughts of suicide is higher among BAME groups according to a study using data from the COVID-19 Social Study:

Evidence suggests an increase in the proportion of BAME young people presenting with thoughts of suicide and anxiety/stress compared to white young people.

BAME children and young people may also be experiencing the pandemic differently.

BAME patients accessing mental healthcare face a negative pathway compared to White patients:

Black men are more likely to experience a psychotic disorder compared to White men:

Young Black women are at greatest risk of self-harm, although less likely to receive psychiatric care:

Among in-patients, Black African men have the highest rates of suicide compared to White British men:

Older South Asian women are at an elevated risk for suicide:

How should services meet the needs of BAME groups?

Social stigma around mental health is a perceived barrier for help-seeking among people from BAME groups:

Community delivered mental health awareness workshops may help to reduce stigma:

NCISH recommends that services should address the complex social and health requirements of people from BAME groups. We found, for example, unemployment and non-adherence to medication were more common than in White patients:

A literature and evidence review outlines what mental health support can be effective for BAME groups:

Guidance on risk mitigation for BAME staff in mental healthcare settings:

Support for students and older people

Guidance for supporting students during COVID-19

A number of universities have reported that teaching will move from face-to-face to remote methods for part or all of the 2020/2021 academic year. Ensuring that universities continue to focus on student wellbeing in future planning is vital:

Ideas on how to support students during the pandemic, including changing the delivery of student mental health support:

Additional guidance on supporting students with pre-existing mental health conditions and students remaining on campus:

Guidance from StudentMinds on supporting students during the pandemic, including specific resources for students to use:

Guidance for supporting older people during COVID-19

Public Health England’s initial guidance for people aged 70 or over was strict adherence to social distancing and self-isolation to shield themselves and people they may live with, to reduce their risk of contracting COVID-19 (this advice was withdrawn on 1 May 2020 and replaced with advice to minimise contact with others outside their household):

Concerns about the potential adverse physical and mental health outcomes of these measures in older people have been raised:

However, interventions to counter suicide risk factors in vulnerable groups have been suggested:

The Inter-Agency Standing Committee suggests interventions to support older adults during the pandemic:

Suggestions, including cognitive-behavioural strategies, for how clinicians can help older patients maintain social connectedness during social distancing restrictions have also been addressed:

The Mental Health Foundation has COVID-19 specific guidance for older people. This includes practical tips and suggestions on how to occupy their time. It also advocates for people to contact their GP regarding their physical and mental health if required:

Age UK has published tips about staying safe, keeping busy and active at home and how to stay connected with others while social distancing. A guidebook about the coronavirus and a telephone line for advice are also available:

The Silver Line, a helpline for older people, has information about the coronavirus and a telephone line that is open 24 hours a day, seven days a week:

Independent Age has resources including information on how relevant services have changed due to the pandemic, and practical advice on issues such as home deliveries:

What impact has the COVID-19 pandemic had on older people’s mental health?

Older people with pre-existing mental health conditions (and their friends and families) have self-reported an increase in symptom severity:

This article outlines how COVID ageism can negatively affect the mental health of older adults through worry and fear about the virus itself and a feeling of burdensomeness on society and healthcare services:

Older adults in the US have reported higher depression and greater loneliness following the onset of the pandemic:

 

Suicide data and statistics

How have suicide rates changed over time?

Suicide statistics are based on the National Statistics definition of suicide; including all deaths from intentional self-harm (ages 10 and over), and deaths caused by injury or poisoning where intent was undetermined (ages 15 and over):

Since 1981 suicide rates have been on a general downward trend in England, with a record low seen in 2007, followed by a post-recession rise.

Males aged 10 to 24 years have consistently had the lowest suicide rates, although this rate increased by 25% from 2017 to 2018. Before 2012, males aged 25 to 44 years had the highest suicide rates however since 2013 the highest suicide rates are seen in males aged 45 to 64 years.

Suicide rates increased by 83% in females aged 10 to 24 years from 2012 to 2018. Since 1981 suicide rates in females aged 45 years and over have reduced significantly, although those aged 45 to 64 years still have the highest rates overall:

How will the change in burden of proof affect suicide rates? 

The change in the standard of proof for suicide at inquests may well lead to some increase in deaths recorded as suicide, although it is important to remember there are other factors which could contribute as well. We should also bear in mind that the increase reported in 2018 began even before the change in coroners’ practice:

What is a Real Time Surveillance (RTS) system?

A RTS system for suicide has two major purposes: (i) to track local suicide trends and (ii) to provide timely bereavement support. A multi-agency approach is important and it can be specially important to involve the police and coroners:

In addition to collecting suicide data, it is useful to collect data on self-harm, an important predictor of suicide. The “iceberg model” refers to three levels of self-harm: (i) the tip is fatal self-harm (i.e. suicide); (ii) the middle section is self-harm resulting in presentation to services; and (iii) the largest submerged part is self-harm that occurs in the community:

Data on self-harm typically captures the middle section of the iceberg and is collected in general hospitals. The Multicentre Study of Self-harm in England collates data from three centres across five hospitals. We are also working with selected sites to provide timely data on self-harm for the period of the pandemic:

Collecting self-harm and suicide data can also reveal other risk factors, such as domestic abuse:

Data on community episodes of self-harm are also available:

What impact has the COVID-19 pandemic had on self-harm and suicidal behaviour?

Our examination of suicide figures from established RTS systems in several parts of England found no rise in suicide after lockdown:

A living systematic review, which reviews all studies of COVID-related suicide prevention, concludes there is currently not sufficient evidence of an increase in suicide or self-harm associated with the pandemic:

Responsible media reporting of suicide and self-harm

The careful and accurate reporting of suicide is vital, even more so during the COVID-19 pandemic.

The media covering positive coping stories in difficult situations could have protective effects:

Talking about suicide in the right way can reduce suicidal ideation in treatment-seeking populations:

Children and young people

What are the concerns about children and young people?

A follow up report to the Mental Health and Young People Survey 2017 found rates of mental disorder in children aged 5 to 16 have increased since 2017:

Guidance about children and young people

How to help a young person if there are concerns they may be self-harming:

How parents and carers can support children and young people of different ages, including accessing mental health services:

Can suicide happen without warning?

In our NCISH study examining suicide in children and young people, 30% had no known history of suicidal ideas or self-harm. This group also had low rates of other risk factors for suicide. This may be because some young people hid their distress or signs of emerging risk were missed. It could also be due to rapid escalation in suicidal feelings in response to adverse events:

60% of 10-19 year olds who died by suicide had been in contact with specialist children’s services, most often with mental health services.

Is there any evidence for suicide in young people with autism spectrum disorder during the pandemic?

The National Child Mortality Database (NCMD) have developed a real-time surveillance system on likely child suicide rates during the COVID-19 pandemic in England. There is limited evidence of increased suicide risk in children with ASD or Attention Deficit Hyperactivity Disorder (ADHD) – 6 (25%) children who died by suspected suicide had a diagnosis of ASD and/or ADHD. Findings indicate a possible increase in child suicide deaths during the initial 56 days of lockdown. However, these findings should be interpreted with caution due to small numbers and suicide risk remains low:

What are the risk factors for suicide and self-harm in children and young people?

There is some evidence that absence from school is as a risk factor for self-harm and thoughts of suicide:

There are several antecedents to suicide in young people, particularly girls, including bullying, self-harm, bereavement, and academic pressures, which are important in a multiagency approach to prevention:

The National Society for the Prevention of Cruelty to Children (NSPCC) have guidance regarding online safety during the COVID-19 pandemic, including how to talk to children about online safety:

How can the mental wellbeing of young people be supported?

The NHS Long Term Plan (2019) sets out the aim for a further 345,000 children and young people aged up to 25 years to be able to access NHS mental health services, and mental health support teams in schools or colleges by 2023/24:

The closure of schools and universities interrupted the education of young people. It is important for academic institutions to continue to provide teaching during the pandemic and, where required, for the government to provide funds to assist with this:

Time to Change have a number of resources to help teachers with talking to students about mental health such as ideas for school assemblies:

Many mental health services are continuing to offer support via the telephone and online, including for young people. Information for parents supporting their child(ren) during the pandemic are available from YoungMinds, including how to access routine and urgent mental health care:

Dialectical behaviour therapy was found to be effective in decreasing repeat suicide attempts in adolescents in one study but the evidence base for interventions for self-harm in young people remains patchy:

 

Webinars

We are working with experts in quality improvement at the National Collaborating Centre for Mental Health (NCCMH) to provide interactive webinars for sharing ideas and learning how to respond to local areas’ concerns over the impact of COVID-19 on suicide and self-harm prevention.

Upcoming interactive webinars

Details of upcoming webinars will be published here when available.

Previous webinars

Suicide prevention for children and young people

Wednesday 22 July 2020, 10-11am

This webinar discussed what is known about suicide risk in children and young people during the COVID-19 pandemic, how the impact of COVID-19 on self-harm and suicide rates is being measured and reported, and how mental health services are continuing to adapt; we were joined by Lara Ferguson (Researcher and Lived Experience campaigner).

Suicide prevention and changing mental health services

Wednesday 3 June 2020

This webinar discussed the challenges mental health services are facing during the COVID-19 pandemic, particularly how we manage the mental health of healthcare workers and suicide prevention in Black, Asian and Minority Ethnic (BAME) groups; we were joined by Ananta Dave (Medical Director, Lincolnshire Partnership NHS Trust).

How has COVID-19 changed suicide prevention?

Wednesday 6 May 2020

This webinar discussed the impact of COVID-19 on suicide and self-harm prevention, and emerging priorities for prevention; we were joined by Caroline Harroe (CEO of Harmless).