Welcome to the Oxford Psychiatry Podcast series brought to you today by me, Daniel Moore.
Today I have Professor Keith Horton with me.
He is professor of psychiatry at Oxford University and has been working in the field of research into suicide and self-harm for more than 35 years.
Professor, I was wondering whether we could start with well, really, what sparked your interest in this area?
What led you to being a professor in this particular area? Well, it was an interesting beginning.
It was essentially chance. And when I completed my training, my consulting boss at the time who was a researcher,
had funding to do research on self-harm and said, was I interested now since many, many, many years ago?
And I've stayed in the field ever since, as it has become apparent, there are so many aspects to this particular issue,
and particularly when one thinks about treatment and prevention as well.
Maybe we're going to talk a bit about all those different aspects in a few minutes.
But could you just outlined for people who might not be so familiar with what we're talking about here.
Can you give us the clinical context of of self-harm or suicide?
What does it look like on the ground? What are we seeing clinically?
Well, one important fact is that people who die by suicide, something like just over a quarter,
have been in contact with a mental health professional in the year before death.
This means, of course, that psychiatry has a very important role in suicide prevention.
But it also means that if you're going to think about suicide prevention broader, more broadly,
you have to think about the other 75 per cent of people who don't come into contact with mental health services.
It doesn't mean they don't have psychiatric disorders, of course, in terms of specific clinical conditions.
Suicide is, in a sense, the the worst outcome in psychiatry on a wide range of clinical conditions.
And every psychiatric disorder is associated with an increased risk of suicide compared with, say,
the general population, except perhaps dementia, although the risk may be increased in early dementia.
So depression is is the most important condition in the sense that something like 50
percent of people who die by suicide or at least 50 percent have evidence of depression.
Whether or not they've seen a clinician, one can find evidence talking to relatives and so on and so forth.
But it is also an important complication of disorders like bipolar disorder, schizophrenia,
eating disorders, alcohol related disorders, and particularly when there is a multiplicity of disorders.
So people who have depression and alcohol misuse, for example.
So with all that, those broad ranging conditions that can lead to this really bad outcome of suicide,
what is it that you look for in a suicide or self-harm assessment?
One of the things you're really focussing in on? Well, there are a number of key factors.
One is, of course, are people thinking about suicide and obviously, are they feeling hopeless, pessimistic about the future?
One wants to know about things like their family history of family.
Their family history of suicidal behaviour can be important because there's a genetic component to suicidal behaviour.
Have they ever self-harm in the past? That greatly increases the risk of future self-harm and suicide.
But what one's trying to do ideally is to think about that individual in their personal circumstance,
their particular social setting and the sorts of issues they are facing,
and not so much in terms of generic risk assessment, which I think can create problems,
but more about that individual and what what we can do to reduce risk.
It's all very well identifying risk when we become risk obsessed.
It's thinking about risk reduction and seeing the person in that context understanding the story.
Absolutely.
There are lots of constraints in the health care system at the moment, and there's lots of change in any departments in psychiatric services.
Are there any key challenges about this, you know, the whole context of health care services that relate to to your area of work?
Well, perhaps the main one is the current very serious problem of emergency departments.
As you know, there is a huge pressure on general hospital emergency departments and a push to get people through them as fast as possible.
Now, we know that somewhere between 200000 and 300000 episodes of self-harm present to general hospitals each year.
Now, we also know that you can't dismiss someone who's harmed in a few minutes.
You really do have to spend quite a bit of time understanding this story, talking to other informant's, relatives,
general practitioner and so on, in order to safely assess that person's needs and risks and decide about what may be helpful for them.
That is very difficult in the context of a very pressurised emergency department as an added issue is that and you could say to some extent,
understandably, general medical staff and nursing staff tend to have rather negative attitudes towards self harm patients, partly because,
you know, they're dealing with someone who's self-inflicted, if you like, the problem or problem that brings them to the hospital.
And because they may not see the problems that self-harm patients have as being particularly relevant to the rest of their work.
So this creates creates issues.
And it also it means it also means that self harm patients often report very negative experiences of going through emergency problems,
and that makes their care difficult, particularly in their care. Later, that might be provided by the psychiatric service.
The really wide variety of patients going into the emergency departments is very
difficult with the constraints to provide these different sort of pathways or streams.
Yeah, I can see that you've been a UK leading expert in this area for many,
many years and you've been involved in some really interesting projects during that time.
And one particularly interesting project was to do with the packaging of paracetamol.
And would it be OK if you could just tell us a bit more about that? Well,
we became aware during the 1980s and 1990s that there was a major problem developing
in this country with increasing numbers of people taking overdoses of paracetamol.
And this has a particular risk of causing liver damage and and can cause death.
And so the numbers of deaths from this method were increasing.
And we also knew that from a study we did locally, that people who take paracetamol overdoses, often these are very impulsively.
In other words, they really thought about it for perhaps a few minutes beforehand. They tend to take what's available in the household.
Word can obviously go out and buy. And as as a result of this, the that was that contributed to a decision by the regulatory agency,
the Medicines and Health Products Regulatory Agency in the UK,
deciding in 1998 to introduce smaller packs of paracetamol on both those sold in pharmacies,
chemists and sold through other outlets, supermarkets and so on and so forth.
And we've been monitoring the impact of that.
We've done our three evaluations and have shown pretty positive benefits of that in terms of deaths from
paracetamol over those people having to go to liver units because of the effects of paracetamol overdose.
And we've shown that the size of paracetamol overdose has been reduced.
So that's been a pretty positive effect of that intervention.
A very interesting finding.
On a different note, a few years ago, you edited the book, Prevention and Treatment of Suicidal Behaviour From Science to Practise.
Can you tell me about your thoughts? I mean, you must have learnt so much in so many different ways,
but are there any of key messages that you've learnt over the years and your experience regarding prevention of.
Suicide in the clinical context, well, the first one, and perhaps most important is the is the fact that suicide can be prevented.
I'm not saying all suicides can be can be president necessarily saying all suicides should be prevented, prevented.
But we know that many suicides can can be prevented.
And we also know from people who survived very serious suicide attempts that they often report being extremely grateful.
The suicidal impulse is often very short lived. And if people can be seen through to the end of it, then they're often gravely glad to be alive.
And that's that's that's really an important fact.
Another aspect is we know that, you know,
having the means available for suicide can be an important influence on people thinking about suicidal behaviour.
And of course, if more dangerous means are available, then it can increase the risk that people will die by suicide.
And that obviously has important implications when thinking about prevention initiatives.
I think another very important aspect of this relates to what I said earlier about thinking about the individual in their own
social and human context and trying to understand the individual in terms of what might propel them to to to to suicidal acts,
rather than thinking everybody is the same. And you can sort of, you know, take a checklist of risk factors,
which I think is a very bad habit that has crept into the health health system, you know,
in these days of being obsessed with risk and perhaps not thinking enough about, you know,
what can one do to help the individual rather than just label label their risk.
It's very interesting to hear you speak about the patient's story,
because there is this drive to with the suicide inventory risk inventories to go through and take to make sure that everything is signed off,
as it were, and that the risk has been calculated. But actually,
what you're saying is the patient's story of finding the individual within that context and knowing about their relationships and their
their day to day life is gives you the key to to really what the what their actual risk is and and and how to best manage the patient.
Absolutely. Okay. I'm going to ask you a question which might not have a clear answer attached to it, but I'm just interested in your opinion.
Professor, do you think the government's suicide prevention strategy, which was published in 2012, is proving successful at the moment?
Well, I think it's too early to say in terms of the the current suicide prevention strategy,
because we had an earlier suicide prevention strategy published in 2002.
And it's interesting, if you look at suicide statistics, we had a steady decline in suicide rates until 2007,
when, of course, unfortunately, the recession came along, the worst economic recession probably ever pretty well.
And of course, that's an inevitable negative effects related to suicide.
Now, I wouldn't wish to say that all the decline in suicide rates that we've seen following the first strategy were due to the strategy.
I think that's unlikely, but I'd like to think that some components in it contributed to that fact.
The important thing about having a strategy is that it makes the people think seriously about suicide prevention.
And I think that's one of the major benefits of this.
And, you know, if I go back 20 or 30 years, people didn't talk that much about suicide prevention.
Certainly in terms of the population at large, obviously within psychiatry, we were concerned about it.
But, you know, as I said earlier, you have to think more broadly in psychiatry and psychiatric services,
security and thoughtful, thoughtful about prevention of suicide in the nation.
And in some ways, I would see that as the most useful component of what the new strategy has particularly
done is that it's highlighted the needs of people bereaved by suicide as well as,
you know, what you can do about suicide prevention. And I think that's a very positive benefit and we're seeing some spinoffs from that
developing as people are thinking more and more about helping this group of people.
And we know that every person who dies by suicide, something like 68 people, are going to be severely affected by that.
And so you're talking about 30 to 40, 45000 people a year.
And that, I think, has been a certainly a tangible benefit.
Not sure there will be more as time goes on.
Do you think the nice guidance that's the National Institute for Health and Clinical Excellence, Steve, they produce some guidance in this area.
Do you think that's been helpful? I think it's been extremely helpful.
The 2004 nice guideline, the first one on self harm,
particularly highlighted the need for a development of good services, self harm patients, which is important.
And secondly, the need for every self harm patient going through a general hospital to have a psycho social assessment of their needs, risk and so on.
Unfortunately, while we've got evidence that services have improved since that time,
it doesn't appear that the proportion of patients receiving a psychosocial assessment has changed.
And we know this from a 32 hospitals study that we did before that previous before the government and more recently.
So there's an issue, there is a clear recommendation, and yet it isn't happening.
And I'm sure all the pressure has developed on emergency departments would have been one factor in that.
In the new guideline, there are a number of other recommendations.
One very important,
which we've touched on two or three times in our discussion is about the need to get away from from relying on risk assessment tools.
And I think that's extremely important. Another recommendation,
and it comes out of a Cochrane review that we did and contributed to the nice
guidance is that short term psychological therapy can be beneficial for for not all,
but for many people who self-harm. We're quite a long way from having that available.
Every service, but that nice now recommends that that should be available in services.
So I think in time we will start to see more benefits of that nice guidance.
But it's happening much slower than one would have liked to see him. Well, thank you very much for answering those those questions.
It's been really interesting to hear your view on this controversial, interesting, high, high profile area.
And before we finish, it would be really great to have some thoughts from you about any listeners,
any any school students or any medical students or any maybe foundation doctors who are contemplating a career in psychiatry.
Any words of advice or any thoughts you might have for them?
Psychiatry is a fascinating subject and it has so many facets to it that make it constantly challenging, constantly interesting.
And one of the issues we face is that are quite a lot of negative attitudes towards psychiatry and not just in general,
but even amongst our medical colleagues and doctors in training that expose those to the general hospital,
which is really unfortunate because the the the depth of interest that psychiatry brings being ranging from psychological issues,
social issues, indeed, political issues that are relevant to our patients,
along with all the physical aspects of psychiatric disorder is is constantly challenging, constantly fascinating.
It's a speciality that I think is terrific. I have no regrets about coming into this.
I did medicine in order to go into psychiatry and certainly have never regretted that.
Well, thank you for that, that those positive words.
So I was just been a real pleasure speaking to you. And thank you very much for your time, Professor.
And thank you for tuning in to the Oxford University Psychiatry podcast series.
We hope you listen to some others after this.
And we just like to also say thank you to Wayne Davis, who's part of the production team for this podcast series.
Thank you. Goodbye.