Welcome to the season of Future Makers Brain and Mental Health.
I'm Professor Belinda Lennox. I'm a psychiatrist and a researcher here in Oxford.
And this season, you'll be joining me as we demystify the science behind the most complex object in the known universe,
our brains, and look at the wide reaching impacts of mental illness on individuals and society.
I'll be introducing you to some of Oxford's best academic minds working to solve the greatest challenges in brain and mental health.
And I'll also be speaking to guests from beyond the university to bring their
perspectives and lived experience and get a sense of the impact of what we're doing.
Join us as we discover how Oxford is shaping the future of brain and mental health research.
In this episode of Future Makers, I'm delighted to be joined by my colleague,
Professor Saeid Fazal, to talk about current research around suicide and suicide prevention.
Senior is professor of psychiatry, consultant, forensic psychiatrist and the new director of the Centre for Suicide Research in Oxford.
Oxford has a really proud tradition of suicide research over many decades, doing research into the nature causes and of suicide,
and translating those findings into prevention, treatment and improved support.
And this was pioneered by the work of Professor Keith Horton. In fact, actually,
the rates observation of suicide amongst university students was one of the
reasons that the University Department of Psychiatry was founded 50 years ago.
But the work of Keith was really important. In the 1990s, he revealed the extent and characteristics of suicide following paracetamol overdose.
And this work led to the UK legislation that restricted pack size in 1998.
And he and colleagues then showed that this reduction in pack size was followed by a substantial reduction of over 30% in the
number of deaths from paracetamol poisoning and actually work ten years ago now showed that that benefit had been sustained.
Although maybe we might come on to discussing whether that's actually still the case nowadays.
But further work from from Keith and from this department showed the particular fatalities and the
danger of co proximal which is another painkilling drug which is a paracetamol plus another compound.
And it showed that it was particularly toxic in overdose.
And that work led to the withdrawal of CO proximal in 2008.
And again that that group showed that that corresponded with a reduction in deaths due to poisoning with that drug.
So basically the research, the observation, the description of the means of suicide and restricting those means is actually a
really powerful public health intervention that could be used for suicide prevention,
I think is almost the most powerful way that research can influence reduction in suicide rates going forward.
I'm sure we will discuss it, but to bring you in, since your work particularly focuses on high risk populations, doesn't it?
I want to describe a little bit about the work that you've done over many years now.
Yes. So I've focussed, as you say, mainly on high risk populations and they include people with certain medical conditions,
usually neuropsychiatric conditions like severe mental illness such as schizophrenia,
bipolar disorder, but also what I think are relatively neglected conditions, but also very common conditions like traumatic brain injury, epilepsy.
And then we've also recently looked at a large number of people with quite chronic physical health problems like diabetes,
lung diseases, heart diseases, and looked at their suicide risk.
And we've been interested in those groups in particular because they are groups of people that do access medical services.
So there is a potential to intervene and that's important.
And we also know that there are good quality interventions that can be offered to those people.
The second group, high risk group, you call them high risk group, are people in touch with the criminal justice system.
So a lot of people every year arrested. Most of those people aren't charged.
But we know that the whole process from arrest all the way through to being in prison and
then being released from prison is associated with quite high risk of of suicide death.
And again, because they're in contact with services, sometimes not very good contact with medical services,
but they're in contact with some sort of services from the state.
They are interventions that can be offered and provided, and there are areas which can be improved.
So these are all areas where there are very discrete changes that can be made that can improve things.
And the point you make about paracetamol is a very good one because restricting access to means has been the most powerful,
I think, approach to suicide prevention in the world to date.
And there are simple things you can also do.
For instance, in prisons where I do some clinical work, you know,
removing ligature points are points that people can use to attach things like sheets
that they used to sleep in or they they create types of ropes from sheeting.
I mean, just removing those is a very simple intervention, very scalable that you can intervene and and administer widely,
implement widely so that they're there are some examples of where, you know,
the high risk groups have been identified in the work we've done and then the and then what we've been trying to do is,
is not only point out the these the risk is high in these groups, but also what you can do to improve your assessment and then also your treatment.
So we the approach we've taken is really a.
Holistic. If you want to be looking at the problem where the problem really exists and what can
be done to improve the assessment and then the treatment to management of the problem.
Yeah. So there's so many things I want to discuss from that.
I suppose one thing that immediately arises, you say something simple like reducing, taking away look at you.
I mean, it's just seems such common sense, doesn't it? It also seems so simple.
And. And I suppose just thinking through, you might think, well,
why does removing the means if you have somebody that really, you know, wants to die is suicidal.
Why does such a simple thing actually, I mean, wouldn't somebody then go and find another way.
Yeah. Well, that doesn't seem to be the case. I mean, usually when people have a very acute suicidal thoughts and it doesn't last very long,
and and so sometimes it just goes away, you know, with time,
and sometimes it goes away with with some sort of contact with, let's say,
a family member or friend or, as I say, just goes away because it's a temporary event.
And so that's one of the key things, is that because it's very time limited, then having interventions like this, it's quite important.
I mean, interesting enough in the US, you know, the the means that people use to die from suicide are guns.
And so actually having restrictions on on on guns among people who mental health conditions actually reduces suicide risk.
I mean, a lot of the focus is being in legislation on people being dangerous.
But actually that's not really where the the focus should be.
I think the focus should be on suicide prevention.
And the and that's really where the research should be points towards really that by restricting guns,
you can reduce suicides among people with mental illness because again,
it's the it's having the means having it easily available, which is is the thing to address in the UK.
I mean there was quite a innovative in a way, but also evidence based intervention where they remove ligature points from hospitals,
from psychiatric hospital wards, inpatient wards, and that led to a reduction of suicide in inpatients.
And that's been shown to have been, you know, quite, quite a large reduction in suicide rates.
And that, again, it's it's an example of where good quality research can lead to a simple,
scalable intervention which can then lead over time to reduction in rates.
Yeah, Yeah. I want to ask you a bit about methods of before people.
So sort of thinking, oh, this is going to be I think this is really actually of key importance because describing as you do a lot,
you look across whole populations, don't you really comprehensive data sets and you look to go beyond just the associations of what's
associated with suicide in a particular population or particular characteristic to really get it causation.
And that's really absolutely key, isn't it? Because otherwise you get kind of wrong messages.
For instance, you know, a lot of noise about antidepressants make people suicidal, for instance, a sort of fallacious argument.
But actually that's why you need high quality epidemiology, isn't it?
I think so. And I think that's the area where I think we've done the most.
I suppose the the most innovative work is around methods, is trying to work out how to disentangle really quite complex.
Series of issues and suicide is usually caused not just by one factor, but an accumulation of multiple factors over a life course.
So how can you disentangle the relative strength of one particular risk factor that you want to isolate and ideally then prevent or treat?
It requires quite a lot of thinking and careful work.
And actually one of the I think one of the things that we've done very well is we've we've harness the power of large data, big data,
but not just that having good quality methods is key because you can have large data,
but if you analyse it superficially, you get the wrong, you can get the wrong answers.
But what we've tried to do is be very careful about how it's analysed.
We've used new methods such as for instance, one of the methods we've used is using sibling controls,
where this is using a brother or sister to someone who has, let's say, a disorder of interest.
So for instance, you could look at someone with a head injury and then you compare the sibling who doesn't have a head injury,
this same sex sibling who doesn't have a head injury. And then you follow those two people up over time and ideally,
you really follow them for a long period of time because you need that longitudinal perspective to make sense of the information.
And that enables you to disentangle someone's background that you know, that the child had background that they share a family background,
the family influences that they share from the impact of a of a head injury.
In this case, it may also be another piece of what we did was an epilepsy.
And that was, again, I think at the time it was a new piece of work.
People hadn't really studied epilepsy in this way.
And again, it's very, very common condition can be treated, very important condition to to treat effectively.
But we highlighted the importance of the suicide risk and the importance of of of being
aware of that and addressing it over the period of the whole period of the illness,
not just right at the beginning or in the middle of the illness.
So when someone has an acute episode, a relapse of some sort.
So methods are important. And I would say the other thing about methods,
I think the department again is really a leader in this is that we've we triangulate the evidence with systematic review.
So systematic review is a way of bringing together in a transparent, comprehensive way information about.
Let's say, risk factors or treatments, bring it together, making sense of it.
And what we've tried to do is, is is use that approach with all these epidemiologic approaches and sort of triangulate
those there's those different pieces of information because it's a complicated jigsaw.
You really need to triangulate the information to make sense of it.
And good quality reviews can be very difficult to do. People think it's simple.
Oh, you just going away of a week and and, you know, and a search on the search engine and put the information together.
Actually, my my experience has been that, you know, good quality ones take years to do.
They need to be updated also regularly. They require quite a lot of thought and care.
And you've got to get the question really right.
You've got to get the your approach really right, how you deal with all the potential spurious associations that you find.
So I think that that's also part of this is not just using good quality methods to interrogate new large datasets,
but also situating that in the context of good quality reviews.
And I think that's something that we've been doing for 20 years now really well, and that by using this method of sibling control,
so really controlling for absolutely everything apart from as well as much as you possibly can other than the event,
the head injury or the epilepsy and then looking for outcomes.
Has anything surprised you? I mean, I mean, did anything fallout,
anything novel that you found that previously perhaps might have been associated with outcomes of head injury or epilepsy?
Well, I think I mean, I think we were able to, I think, confirm what some studies had suggested.
So for instance, and we were able to give some sort of magnitude to the risk of the estimate.
So it's quite important. So you can say something is a risk factor but doesn't necessarily really help you if it's a very small impact or very low.
But you want to know if it's small or very large because that will influence.
You know, to what extent, you know, you focus your resources on that particular risk factor.
So in the case of head injury and epilepsy and these co-morbid physical health,
chronic physical health conditions and all of those, we were able to provide some some precision to the magnitude of the effects.
We also able to clarify that there was an effect because I think in the past, for some of them, there's been a bit of uncertainty.
People weren't sure. Is it the people who have head injury anyway because they're impulsive and maybe these people are just impulsive by nature.
It's got nothing to do with head injuries who are able to to, in a sense clarify that question.
For schizophrenia, bipolar disorder, we've done similar work as well.
And again, what that does is it help it helps provide some precision of the match, matches the effect and highlight the man's effect.
The one area I think there was a bit surprising for us was that we looked at the very large number of people who get community sentences.
So these are people who don't get very serious, who haven't committed very serious crimes, but nevertheless have convicted of a crime.
And there we just published a study actually last week where we found really quite high rates of suicide in people.
And by high just mean relative to what you would expect.
So, you know, two or three times more than you'd expect. And that was new again, I think, and and important,
because that isn't something that people even think about when they're looking at how to manage
people in the community who've had these these type of sentences they think very much around.
The risk of committing a new offence rather than the wider question,
which is the health needs and often the mental health needs and substance misuse needs,
which are the two main drivers, I think of suicide risk in that particular high risk population.
Yes. Can I ask you about the tricky relationship, an association between mental illness and suicide and I suppose the treat ability.
So what happens if you treat the mental illness?
Does the suicide risk go away entirely? What's that? What's the link between the two?
Well, I think part of it, it depends on the particular diagnosis.
So I don't think it's easy to say whether there is a straightforward link between all mental illnesses or mental conditions,
health conditions and suicide. Part of it depends on the diagnosis.
And I think you've got a little bit of a hierarchy in the sense of which has the strongest effects,
and it's usually the most severe end of the spectrum that have stronger effects.
So by this I mean schizophrenia, spectrum disorders, bipolar disorder, they have the the the strongest effects with with suicide risk.
And what we know, at least in bipolar disorder, from very good quality evidence, this is trial evidence, is that lithium in particular,
which is commonly used in people with bipolar disorder as a medication to help treat the condition is associated with reducing suicide risk.
And that's completed suicide, not just self-harm only, but but also completed suicide.
For schizophrenia, it's less clear because there is some evidence and it's looked at mortality and it shows a reduction in mortality,
overall mortality. But it's less clear because the trials haven't really had the length of time that's needed to follow people up.
Sometimes. Charles don't even look for the outcome of the suicide risk, and sometimes they're not large enough to look at it.
So in that case, you really need to triangulate that evidence with other forms of evidence using real world, what we call real world evidence.
So you look at populations that are being treated with, let's say, antipsychotic medication and see what happens.
There is some work done in Sweden and in Finland which shows that antipsychotics are associated with reduction suicide risk.
So I think in some conditions we have trial evidence.
In other conditions, we have what's what's called observational epidemiological evidence.
In some conditions we don't really know.
And you mentioned in your introduction you had difficulty with anti depressants making sense of that information.
And the difficulty there is that when people are prescribed antidepressants,
often because there's an acute increase in their suicide risk, and so that if you do see any people who self-harm or die from suicide,
particularly early on in their treatment,
it may be because they're on a trajectory which is towards increasing suicide risk because their illness is worse,
a depression is worse and that's why they're getting the medication. So you can that's a very difficult area to disentangle.
And there you really need to look at, you know, long term outcomes of people that are 92 presence.
And there again, the trials are suggestive, but they you know, they they don't usually live long enough.
They they're necessarily they're quite short term because they're looking at symptoms of depression.
But overall, my impression from that evidence is that it's depressants are associated with a decrease in suicide risk.
That's my impression. And but I think the difficulty is how you make sense of the first few months and the first
few months is really complicated by lots of other things happening at the same time.
So you will find some papers and some research findings to show a slightly increased risk in the first few months
and others that trying to account for it and don't find that and some that actually find a reduction in risk.
So you can find all three.
And I think probably my view is that it's better to look longer term because then you can see a clearer pattern emerge, which is the decreased risk.
Hello. I hope you're enjoying this episode of Future Makers Brain and Mental Health.
If you'd like to learn more about our work here in Oxford, head to OCS, dot, AC, dot, UK,
forward slash brain or let us know what you think on social media using the hashtag.
Oxford Brain. Can we move on to the area of risk prediction,
which is another really difficult area because I suppose on the one hand I would say
this is absolutely a core part of what a mental health service should be doing,
should be risk assessing and providing tailored individualised treatments that reduces people's risk and keeps them safe and keeps other people safe.
It's a very difficult thing to do and it's a you can get in our area with other mental health clinicians and researchers.
You can get people getting quite shouty about it, can't you, about whether they're actually useful, whether we should throw them all out the window.
What's your view? Well, I think, um, I think that, um, my, my view is they have a role to have a role to support, to enhance clinical decision making.
And I think that very much aligns with the rest of medicine where we use these sort of tools in,
let's say, cancer medicine or cardiovascular medicine to support clinical decision making.
We know that clinicians are not perfect at this sort of thing, that they are necessarily optimistic.
They have to be, I suppose, in order to work in this quite difficult area.
And so they tend to underestimate risk.
They tend to rely on the most recent things that have happened to people rather than look at the sort of longer term perspective.
And again, that's just a bias that human beings have on many levels when it comes to decisions.
And there's a bunch of other biases also that human human beings do have.
And I think then having tools which are structured provides some consistency.
They can sort of help pull up the sort of basic level of quality of risk assessment and then allow
for communication between different services because you're speaking about that same sort of thing.
And they highlight important risk factors which sometimes you forget about to ask.
And they also, I think, underscore what we call safety planning.
And safety planning is where people come up with a a plan about what they would do if they have an acute crisis of some sort.
So particularly the acute suicidal crisis, you know, who they would contact, what they would do in their midst,
let's say, if they were medication, what other support they would try and use.
So I think suicide risk prediction has a role.
And I think a lot of the previous work, which has dismissed it, is based on really old times, old ways of doing things.
So for instance, the most common way people used to do this is by using a checklist which was developed for another purpose.
So for instance, you would use a depression symptom checklist and you would apply it to someone who you're worried about their risk of suicide.
And then you test whether it does a good job at predicting what happens in the future,
let's say future self-harm episodes or even future suicide risk.
And of course,
a depression checklist is was developed 20 years ago for the purpose of telling you how severe depression is isn't going to be very good.
It's a completely different purpose, which was never developed for.
And so a lot of the evidence on this question, a lot of the opinions, including this actually is about those type of tools,
which I think quite rightly are not useful because the tools that were developed for other purposes.
Nice. Nice being the National Institute of Clinical. And yes, so there are a committee of experts who review the evidence.
And and I think that their review of the evidence is right when it comes to these old checklist tools which are poor quality,
they're not validated properly. They wouldn't even develop for the purpose of suicide risk prediction.
So they're right in the sense that, you know, we need to start again.
And one of the things I've been trying to do is start again, actually.
So I've I've developed a number of tools that can be used to inform suicide risk prediction.
And we've developed the tool for people with severe mental illness called locksmiths,
and just published a tool for people who self-harmed could all access.
And then we we just use very modern methods, large data sets transparently reported, easy to score, easy to interpret,
presenting the information in different ways, not just high and low risk, which is very old, I think an old fashioned way of doing it.
But actually probability schools, which is a more modern way of doing it,
akin to having like a probability score of, let's say, dying from another course.
Let's say if you've got a cancer diagnosis, you're given a five year survival,
or if you over the age of 50, in many high income countries, you get a cardiovascular risk score.
So that's the way that things have been moving in the rest of medicine.
I think mental health has been a bit slow to catch up and that's part of our research programme.
And I think I mean, we we know that there's a lot of interest in this,
so we can see from the website traffic on our website where we've got these tools up that we have quite a lot
of take up of these tools and people are using them widely for research purposes as well as to help them.
Think about groups of patients that they may see as well and indicated treatments as a result.
So if you have an increased risk of cardiovascular events, you might start a statin or you might stop smoking.
If you have an increased risk of suicide, you might have help for your alcohol is a problem.
And the arguments against that which which some of the some of the people who get some of you have written about this saves
everyone should get the gold standard so that even if you end up with stratifying risk which is a more technical term,
then that doesn't help you because we should be giving everyone the gold standard.
But I don't think that's realistic. I mean, in a modern healthcare system, you can't give everyone the gold standard.
I mean, everyone that turns up tonight in the John Ratcliffe Hospital, you know, who've taken has taken an overdose,
can't get any sort of gold standard follow up, you know, ten sessions of cognitive behavioural therapy plus, you know, good quality follow up.
And that's just not realistic in most countries in the world.
It's not realistic. And so I think treatments have to be tailored.
They have to be made more precise, but they also necessarily, I think, have to be there has to be some resource allocation and.
One of the useful things about these tools is they can tell you who are the people.
You don't need to do further assessments and further long, you know, treatments and assessments for.
And so you can focus your energies on the group that does does have identified needs and will benefit from further assessment and treatment.
Yeah. And if you are in control, if you are the Chancellor seen and you had your defined budget.
Where would you put it for the most benefit?
I'm just wondering, for instance, for people in prisons, for instance, would you give them a better quality mental health care?
Well, I think I think from a if I was the chancellor, I think a lot of my attention would be on actually funding trials,
because one of the things that struck me and I did a review is that the field for Internal Medicine,
which is a well-known journal in our field, and when I did this review, I mean, I looked very hard for trials of suicide prevention.
And I was surprised and disappointed, actually, that there weren't more trials.
I mean, what seems to be the case is there are many, many trials looking at outcomes such as suicidal thoughts or ideas or even self-harm.
And we know that they're quite different. So the risk factors are different.
What drives people to to self-harm can be very different to what drives suicide mortality.
And I think actually good quality evidence is actually lacking on the most effective treatments for suicide prevention.
So that's where I think. So I would I would put a big investment in the R&D budget.
Oh, thank you very much. Yes, Senior Chancellor.
And I suppose that sort of connects to that. It is surprising to me how it's such a lead.
I mean, this is a public health crisis, actually.
Suicides particularly, You know, it's the leading cause of death in young people.
Absolutely. Yes. And globally, I mean, so 70%, 77% of global suicides occur in low and middle income countries where,
you know, absolute parlous level of research going on into how to improve this situation.
But I mean, and it's linked to the sort of the stigma around it, isn't it?
I don't it's not part of I don't think and sort of people that I talk to that it's seen as a,
a solvable problem as it's something that actually research can provide the answers to.
Maybe that is true. I mean, maybe people don't realise how preventable it really is and that, you know,
these some of these interventions that have happened, you know, you know, simple interventions,
know putting barriers up in bridges to buildings, railways, you know,
making it more difficult to jump from high buildings, putting restrictions on pesticides.
I mean, they're three that there is research, good research to show that they've made big impacts,
actually, so that you can actually make an impact on reducing suicide rates.
So it is something that is preventable. I suppose that's one of the messages that it's not inevitable, it is preventable.
And and I think particularly in high risk groups, we know there are things that can be done.
There is some evidence in people with with underlying mental health and physical health problems
and in certain other high risk groups like people who touch the career justice system,
people who self-harm like we just mentioned.
I mean, they're another really important group because their subsequent rates of dying from suicide are really very high.
And one of the highest groups in terms of humans just take a subgroup that is the highest,
you know, I think in terms of risk in the next year and all those groups,
something, there are interventions that are available,
but I think there's actually a lot of room for more good quality research to highlight other things that can be done.
We don't know a lot about the best services, so mental health services, how they can be better provided, better reconstituted.
You know, you work in first episode services.
I mean, we know it was very interesting study done in South Korea where they looked at the introduction of these services and they showed that
there was a reduction in suicide rates among that population will be very interesting to those that's validated elsewhere in the world.
So there is I think, yeah, for me, the striking thing is that we know now quite a lot about risk factors.
We know a little bit more about the high risk groups, but we don't know a lot about interventions.
And that's, I think where a lot of research effort should be placed.
I think the other thing I think we could do better on is. Assessment, actually.
So I talk about risk factors, but actually what is the case is that it's accumulation of risk factors.
They act at different points in one's person's life, in different strengths.
A clinician can only probably cope with three or four risk factors simultaneously,
but these tools can bring together, you know, ten or 15 simultaneously.
And that's the added value of them, really. You know, when I'm seeing someone in clinic,
I can just about three or four factors together and hold them together and make a judgement about the relative, you know, impact of these factors.
But then anything beyond that, you know, I run out of the sort of computing power and that's where I think,
you know, and, and therefore, you know, there may be developments in artificial intelligence, machine learning.
And we hear a lot of hype about this, and most of it is hype, to be honest.
But if it's done well, I mean, it may also have a role. I mean, how scalable it is remains a question, but I think it needs to be studied.
We need to see what, you know,
what added benefit it does give you and whether that and then we have to decide whether it's worth it with the benefits,
worth it in the in the sense is it worth it because it will cost a lot of money to implement.
But also, you know, it's not as transparent as having the type of tools I've been working on where you can see all the risk factors,
what impact they have, how they interact. Since very transparent open system.
You can see how we developed it. You can see what risk factors we tested.
We can see you can see our methods. But the these new methods to do machine learning, it's it's much more difficult to interpret.
So they may well have a role. And there I think we would have to work quite closely with, I think, medical ethicists, to be honest,
to try and figure out how much added value they can provide and whether that's actually
it's really valuable in the big scheme of things and the acceptability of that,
actually. Yeah, that's a whole different podcast, I think. I think.
Well, though, thank you. Seen a fascinating discussion.
I think that's a good place to leave it. Great. Thank you. I hope you enjoyed this episode of Future Makers Brain and Mental Health.
You can find more episodes of future makers wherever you get your podcasts and more on Oxford's research at Oxford.
AC DC's UK Forward Slash Brain. Thanks for listening.