1 00:00:00,300 --> 00:00:05,620 Welcome to the Oxford Psychiatry Podcast series brought to you today by me, Daniel Moore. 2 00:00:05,620 --> 00:00:08,340 Today I have Professor Keith Horton with me. 3 00:00:08,340 --> 00:00:17,700 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. 4 00:00:17,700 --> 00:00:23,310 Professor, I was wondering whether we could start with well, really, what sparked your interest in this area? 5 00:00:23,310 --> 00:00:29,400 What led you to being a professor in this particular area? Well, it was an interesting beginning. 6 00:00:29,400 --> 00:00:38,670 It was essentially chance. And when I completed my training, my consulting boss at the time who was a researcher, 7 00:00:38,670 --> 00:00:45,930 had funding to do research on self-harm and said, was I interested now since many, many, many years ago? 8 00:00:45,930 --> 00:00:56,580 And I've stayed in the field ever since, as it has become apparent, there are so many aspects to this particular issue, 9 00:00:56,580 --> 00:01:02,220 and particularly when one thinks about treatment and prevention as well. 10 00:01:02,220 --> 00:01:06,180 Maybe we're going to talk a bit about all those different aspects in a few minutes. 11 00:01:06,180 --> 00:01:13,080 But could you just outlined for people who might not be so familiar with what we're talking about here. 12 00:01:13,080 --> 00:01:17,760 Can you give us the clinical context of of self-harm or suicide? 13 00:01:17,760 --> 00:01:21,480 What does it look like on the ground? What are we seeing clinically? 14 00:01:21,480 --> 00:01:29,880 Well, one important fact is that people who die by suicide, something like just over a quarter, 15 00:01:29,880 --> 00:01:35,310 have been in contact with a mental health professional in the year before death. 16 00:01:35,310 --> 00:01:40,440 This means, of course, that psychiatry has a very important role in suicide prevention. 17 00:01:40,440 --> 00:01:45,810 But it also means that if you're going to think about suicide prevention broader, more broadly, 18 00:01:45,810 --> 00:01:52,170 you have to think about the other 75 per cent of people who don't come into contact with mental health services. 19 00:01:52,170 --> 00:02:00,120 It doesn't mean they don't have psychiatric disorders, of course, in terms of specific clinical conditions. 20 00:02:00,120 --> 00:02:08,760 Suicide is, in a sense, the the worst outcome in psychiatry on a wide range of clinical conditions. 21 00:02:08,760 --> 00:02:15,930 And every psychiatric disorder is associated with an increased risk of suicide compared with, say, 22 00:02:15,930 --> 00:02:24,220 the general population, except perhaps dementia, although the risk may be increased in early dementia. 23 00:02:24,220 --> 00:02:33,000 So depression is is the most important condition in the sense that something like 50 24 00:02:33,000 --> 00:02:41,070 percent of people who die by suicide or at least 50 percent have evidence of depression. 25 00:02:41,070 --> 00:02:47,490 Whether or not they've seen a clinician, one can find evidence talking to relatives and so on and so forth. 26 00:02:47,490 --> 00:02:57,540 But it is also an important complication of disorders like bipolar disorder, schizophrenia, 27 00:02:57,540 --> 00:03:09,610 eating disorders, alcohol related disorders, and particularly when there is a multiplicity of disorders. 28 00:03:09,610 --> 00:03:14,610 So people who have depression and alcohol misuse, for example. 29 00:03:14,610 --> 00:03:23,610 So with all that, those broad ranging conditions that can lead to this really bad outcome of suicide, 30 00:03:23,610 --> 00:03:27,730 what is it that you look for in a suicide or self-harm assessment? 31 00:03:27,730 --> 00:03:34,560 One of the things you're really focussing in on? Well, there are a number of key factors. 32 00:03:34,560 --> 00:03:45,990 One is, of course, are people thinking about suicide and obviously, are they feeling hopeless, pessimistic about the future? 33 00:03:45,990 --> 00:03:49,650 One wants to know about things like their family history of family. 34 00:03:49,650 --> 00:03:56,640 Their family history of suicidal behaviour can be important because there's a genetic component to suicidal behaviour. 35 00:03:56,640 --> 00:04:06,150 Have they ever self-harm in the past? That greatly increases the risk of future self-harm and suicide. 36 00:04:06,150 --> 00:04:14,910 But what one's trying to do ideally is to think about that individual in their personal circumstance, 37 00:04:14,910 --> 00:04:20,640 their particular social setting and the sorts of issues they are facing, 38 00:04:20,640 --> 00:04:30,420 and not so much in terms of generic risk assessment, which I think can create problems, 39 00:04:30,420 --> 00:04:37,020 but more about that individual and what what we can do to reduce risk. 40 00:04:37,020 --> 00:04:42,270 It's all very well identifying risk when we become risk obsessed. 41 00:04:42,270 --> 00:04:49,470 It's thinking about risk reduction and seeing the person in that context understanding the story. 42 00:04:49,470 --> 00:04:52,050 Absolutely. 43 00:04:52,050 --> 00:05:00,130 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. 44 00:05:00,130 --> 00:05:09,670 Are there any key challenges about this, you know, the whole context of health care services that relate to to your area of work? 45 00:05:09,670 --> 00:05:17,350 Well, perhaps the main one is the current very serious problem of emergency departments. 46 00:05:17,350 --> 00:05:27,910 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. 47 00:05:27,910 --> 00:05:38,660 Now, we know that somewhere between 200000 and 300000 episodes of self-harm present to general hospitals each year. 48 00:05:38,660 --> 00:05:44,650 Now, we also know that you can't dismiss someone who's harmed in a few minutes. 49 00:05:44,650 --> 00:05:53,080 You really do have to spend quite a bit of time understanding this story, talking to other informant's, relatives, 50 00:05:53,080 --> 00:06:04,870 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. 51 00:06:04,870 --> 00:06:15,730 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, 52 00:06:15,730 --> 00:06:27,070 understandably, general medical staff and nursing staff tend to have rather negative attitudes towards self harm patients, partly because, 53 00:06:27,070 --> 00:06:35,560 you know, they're dealing with someone who's self-inflicted, if you like, the problem or problem that brings them to the hospital. 54 00:06:35,560 --> 00:06:47,470 And because they may not see the problems that self-harm patients have as being particularly relevant to the rest of their work. 55 00:06:47,470 --> 00:06:49,810 So this creates creates issues. 56 00:06:49,810 --> 00:06:58,930 And it also it means it also means that self harm patients often report very negative experiences of going through emergency problems, 57 00:06:58,930 --> 00:07:07,390 and that makes their care difficult, particularly in their care. Later, that might be provided by the psychiatric service. 58 00:07:07,390 --> 00:07:13,030 The really wide variety of patients going into the emergency departments is very 59 00:07:13,030 --> 00:07:19,160 difficult with the constraints to provide these different sort of pathways or streams. 60 00:07:19,160 --> 00:07:25,900 Yeah, I can see that you've been a UK leading expert in this area for many, 61 00:07:25,900 --> 00:07:30,460 many years and you've been involved in some really interesting projects during that time. 62 00:07:30,460 --> 00:07:37,030 And one particularly interesting project was to do with the packaging of paracetamol. 63 00:07:37,030 --> 00:07:42,040 And would it be OK if you could just tell us a bit more about that? Well, 64 00:07:42,040 --> 00:07:48,130 we became aware during the 1980s and 1990s that there was a major problem developing 65 00:07:48,130 --> 00:07:54,700 in this country with increasing numbers of people taking overdoses of paracetamol. 66 00:07:54,700 --> 00:08:03,280 And this has a particular risk of causing liver damage and and can cause death. 67 00:08:03,280 --> 00:08:09,280 And so the numbers of deaths from this method were increasing. 68 00:08:09,280 --> 00:08:19,650 And we also knew that from a study we did locally, that people who take paracetamol overdoses, often these are very impulsively. 69 00:08:19,650 --> 00:08:26,740 In other words, they really thought about it for perhaps a few minutes beforehand. They tend to take what's available in the household. 70 00:08:26,740 --> 00:08:42,040 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, 71 00:08:42,040 --> 00:08:47,830 the Medicines and Health Products Regulatory Agency in the UK, 72 00:08:47,830 --> 00:08:57,850 deciding in 1998 to introduce smaller packs of paracetamol on both those sold in pharmacies, 73 00:08:57,850 --> 00:09:03,820 chemists and sold through other outlets, supermarkets and so on and so forth. 74 00:09:03,820 --> 00:09:07,180 And we've been monitoring the impact of that. 75 00:09:07,180 --> 00:09:16,210 We've done our three evaluations and have shown pretty positive benefits of that in terms of deaths from 76 00:09:16,210 --> 00:09:24,280 paracetamol over those people having to go to liver units because of the effects of paracetamol overdose. 77 00:09:24,280 --> 00:09:30,400 And we've shown that the size of paracetamol overdose has been reduced. 78 00:09:30,400 --> 00:09:37,290 So that's been a pretty positive effect of that intervention. 79 00:09:37,290 --> 00:09:40,150 A very interesting finding. 80 00:09:40,150 --> 00:09:47,560 On a different note, a few years ago, you edited the book, Prevention and Treatment of Suicidal Behaviour From Science to Practise. 81 00:09:47,560 --> 00:09:53,620 Can you tell me about your thoughts? I mean, you must have learnt so much in so many different ways, 82 00:09:53,620 --> 00:09:59,730 but are there any of key messages that you've learnt over the years and your experience regarding prevention of. 83 00:09:59,730 --> 00:10:10,380 Suicide in the clinical context, well, the first one, and perhaps most important is the is the fact that suicide can be prevented. 84 00:10:10,380 --> 00:10:17,880 I'm not saying all suicides can be can be president necessarily saying all suicides should be prevented, prevented. 85 00:10:17,880 --> 00:10:24,390 But we know that many suicides can can be prevented. 86 00:10:24,390 --> 00:10:34,050 And we also know from people who survived very serious suicide attempts that they often report being extremely grateful. 87 00:10:34,050 --> 00:10:45,360 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. 88 00:10:45,360 --> 00:10:49,770 And that's that's that's really an important fact. 89 00:10:49,770 --> 00:10:54,570 Another aspect is we know that, you know, 90 00:10:54,570 --> 00:11:02,400 having the means available for suicide can be an important influence on people thinking about suicidal behaviour. 91 00:11:02,400 --> 00:11:10,200 And of course, if more dangerous means are available, then it can increase the risk that people will die by suicide. 92 00:11:10,200 --> 00:11:18,540 And that obviously has important implications when thinking about prevention initiatives. 93 00:11:18,540 --> 00:11:27,690 I think another very important aspect of this relates to what I said earlier about thinking about the individual in their own 94 00:11:27,690 --> 00:11:41,430 social and human context and trying to understand the individual in terms of what might propel them to to to to suicidal acts, 95 00:11:41,430 --> 00:11:49,380 rather than thinking everybody is the same. And you can sort of, you know, take a checklist of risk factors, 96 00:11:49,380 --> 00:11:55,320 which I think is a very bad habit that has crept into the health health system, you know, 97 00:11:55,320 --> 00:12:02,910 in these days of being obsessed with risk and perhaps not thinking enough about, you know, 98 00:12:02,910 --> 00:12:10,230 what can one do to help the individual rather than just label label their risk. 99 00:12:10,230 --> 00:12:15,570 It's very interesting to hear you speak about the patient's story, 100 00:12:15,570 --> 00:12:25,440 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, 101 00:12:25,440 --> 00:12:29,190 as it were, and that the risk has been calculated. But actually, 102 00:12:29,190 --> 00:12:36,410 what you're saying is the patient's story of finding the individual within that context and knowing about their relationships and their 103 00:12:36,410 --> 00:12:49,020 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. 104 00:12:49,020 --> 00:12:58,260 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. 105 00:12:58,260 --> 00:13:07,410 Professor, do you think the government's suicide prevention strategy, which was published in 2012, is proving successful at the moment? 106 00:13:07,410 --> 00:13:14,820 Well, I think it's too early to say in terms of the the current suicide prevention strategy, 107 00:13:14,820 --> 00:13:21,150 because we had an earlier suicide prevention strategy published in 2002. 108 00:13:21,150 --> 00:13:31,320 And it's interesting, if you look at suicide statistics, we had a steady decline in suicide rates until 2007, 109 00:13:31,320 --> 00:13:39,060 when, of course, unfortunately, the recession came along, the worst economic recession probably ever pretty well. 110 00:13:39,060 --> 00:13:45,330 And of course, that's an inevitable negative effects related to suicide. 111 00:13:45,330 --> 00:13:57,720 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. 112 00:13:57,720 --> 00:14:05,430 I think that's unlikely, but I'd like to think that some components in it contributed to that fact. 113 00:14:05,430 --> 00:14:13,350 The important thing about having a strategy is that it makes the people think seriously about suicide prevention. 114 00:14:13,350 --> 00:14:18,840 And I think that's one of the major benefits of this. 115 00:14:18,840 --> 00:14:26,400 And, you know, if I go back 20 or 30 years, people didn't talk that much about suicide prevention. 116 00:14:26,400 --> 00:14:32,400 Certainly in terms of the population at large, obviously within psychiatry, we were concerned about it. 117 00:14:32,400 --> 00:14:39,710 But, you know, as I said earlier, you have to think more broadly in psychiatry and psychiatric services, 118 00:14:39,710 --> 00:14:43,770 security and thoughtful, thoughtful about prevention of suicide in the nation. 119 00:14:43,770 --> 00:14:50,730 And in some ways, I would see that as the most useful component of what the new strategy has particularly 120 00:14:50,730 --> 00:14:57,180 done is that it's highlighted the needs of people bereaved by suicide as well as, 121 00:14:57,180 --> 00:15:04,400 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 122 00:15:04,400 --> 00:15:09,920 developing as people are thinking more and more about helping this group of people. 123 00:15:09,920 --> 00:15:17,510 And we know that every person who dies by suicide, something like 68 people, are going to be severely affected by that. 124 00:15:17,510 --> 00:15:25,910 And so you're talking about 30 to 40, 45000 people a year. 125 00:15:25,910 --> 00:15:30,960 And that, I think, has been a certainly a tangible benefit. 126 00:15:30,960 --> 00:15:34,970 Not sure there will be more as time goes on. 127 00:15:34,970 --> 00:15:41,910 Do you think the nice guidance that's the National Institute for Health and Clinical Excellence, Steve, they produce some guidance in this area. 128 00:15:41,910 --> 00:15:46,700 Do you think that's been helpful? I think it's been extremely helpful. 129 00:15:46,700 --> 00:15:54,350 The 2004 nice guideline, the first one on self harm, 130 00:15:54,350 --> 00:16:01,400 particularly highlighted the need for a development of good services, self harm patients, which is important. 131 00:16:01,400 --> 00:16:13,600 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. 132 00:16:13,600 --> 00:16:21,470 Unfortunately, while we've got evidence that services have improved since that time, 133 00:16:21,470 --> 00:16:26,510 it doesn't appear that the proportion of patients receiving a psychosocial assessment has changed. 134 00:16:26,510 --> 00:16:35,030 And we know this from a 32 hospitals study that we did before that previous before the government and more recently. 135 00:16:35,030 --> 00:16:41,270 So there's an issue, there is a clear recommendation, and yet it isn't happening. 136 00:16:41,270 --> 00:16:49,010 And I'm sure all the pressure has developed on emergency departments would have been one factor in that. 137 00:16:49,010 --> 00:16:53,580 In the new guideline, there are a number of other recommendations. 138 00:16:53,580 --> 00:16:54,980 One very important, 139 00:16:54,980 --> 00:17:07,190 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. 140 00:17:07,190 --> 00:17:11,690 And I think that's extremely important. Another recommendation, 141 00:17:11,690 --> 00:17:16,130 and it comes out of a Cochrane review that we did and contributed to the nice 142 00:17:16,130 --> 00:17:25,160 guidance is that short term psychological therapy can be beneficial for for not all, 143 00:17:25,160 --> 00:17:30,340 but for many people who self-harm. We're quite a long way from having that available. 144 00:17:30,340 --> 00:17:36,740 Every service, but that nice now recommends that that should be available in services. 145 00:17:36,740 --> 00:17:42,590 So I think in time we will start to see more benefits of that nice guidance. 146 00:17:42,590 --> 00:17:52,030 But it's happening much slower than one would have liked to see him. Well, thank you very much for answering those those questions. 147 00:17:52,030 --> 00:18:00,490 It's been really interesting to hear your view on this controversial, interesting, high, high profile area. 148 00:18:00,490 --> 00:18:07,090 And before we finish, it would be really great to have some thoughts from you about any listeners, 149 00:18:07,090 --> 00:18:16,330 any any school students or any medical students or any maybe foundation doctors who are contemplating a career in psychiatry. 150 00:18:16,330 --> 00:18:20,950 Any words of advice or any thoughts you might have for them? 151 00:18:20,950 --> 00:18:38,080 Psychiatry is a fascinating subject and it has so many facets to it that make it constantly challenging, constantly interesting. 152 00:18:38,080 --> 00:18:48,550 And one of the issues we face is that are quite a lot of negative attitudes towards psychiatry and not just in general, 153 00:18:48,550 --> 00:18:57,490 but even amongst our medical colleagues and doctors in training that expose those to the general hospital, 154 00:18:57,490 --> 00:19:11,770 which is really unfortunate because the the the depth of interest that psychiatry brings being ranging from psychological issues, 155 00:19:11,770 --> 00:19:17,590 social issues, indeed, political issues that are relevant to our patients, 156 00:19:17,590 --> 00:19:31,720 along with all the physical aspects of psychiatric disorder is is constantly challenging, constantly fascinating. 157 00:19:31,720 --> 00:19:39,260 It's a speciality that I think is terrific. I have no regrets about coming into this. 158 00:19:39,260 --> 00:19:44,740 I did medicine in order to go into psychiatry and certainly have never regretted that. 159 00:19:44,740 --> 00:19:49,720 Well, thank you for that, that those positive words. 160 00:19:49,720 --> 00:19:54,940 So I was just been a real pleasure speaking to you. And thank you very much for your time, Professor. 161 00:19:54,940 --> 00:19:58,900 And thank you for tuning in to the Oxford University Psychiatry podcast series. 162 00:19:58,900 --> 00:20:01,930 We hope you listen to some others after this. 163 00:20:01,930 --> 00:20:10,420 And we just like to also say thank you to Wayne Davis, who's part of the production team for this podcast series. 164 00:20:10,420 --> 00:20:12,160 Thank you. Goodbye.