National Suicide Prevention Leadership Group COVID-19 Statement June 2020
As Scotland faces the extraordinary challenges arising from the COVID-19 pandemic it is clear that these are difficult and uncertain times for many people and it is highly likely the impacts of the pandemic on individual mental health and wellbeing will be felt for some time to come. There is global concern that the COVID-19 pandemic may increase suicide rates. Studies of past epidemics support an association between previous infectious disease-related public health emergencies and increased risk of suicide, self-harm and suicidal thoughts. It is therefore critical that suicide prevention is a priority public health issue for Scotland which is integral to government planning now, confidently built on the best evidence of what works to save lives.
The purposes of this statement by Scotland’s National Suicide Prevention Leadership Group are to set out the current position in respect of Scotland’s Suicide Prevention Action Plan; to explain how that plan has been impacted by the COVID-19 pandemic and recommend what pandemic-specific priorities should now be promoted; and to make a recommendation that we build on the challenges and opportunities presented by the pandemic and our responses to create a long term suicide prevention strategy for Scotland.
Mental Health and Wellbeing Response to the Pandemic
The pandemic crisis has generated a range of fast-time responses from national and local government and the third sector and has brought organisations together in collective efforts to mitigate its impact on mental health.
For example, Young Scot, the Mental Health Foundation and SAMH have produced dedicated resources on their own websites to provide information on mental health during the pandemic. Samaritans has launched a new self-help app and has adapted its ways of working to continue to support people through its phone, email and web-based services, 24/7.
In April the Scottish Government launched the “Clear Your Head” campaign to help people look after their own mental health and wellbeing during and after the pandemic. The campaign provides people with practical advice on coping with the current restrictions. Additional funding has also been provided to increase the capacity of NHS24 Mental Health Hub telephone support, increase the capacity of Breathing Space, further develop online services and to extend the availability of digital therapies.
The Distress Brief Intervention (DBI) programme, which was at a pilot stage, has now introduced a DBI (COVID response) which is available nationally. The DBI (COVID response) can take referrals from the NHS24 Mental Health Hub which gives referred people over the age of 16 who are in emotional distress, who do not require emergency clinical intervention and are assessed as appropriate for DBI support, the opportunity to work with specially trained staff for up to 14 days. During this time they can explore the causes of their distress and make a plan to address these issues.
The NSPLG welcomes these and other fast-time and collaborative responses to the impacts of the pandemic and the important role they will play in helping to prevent suicide in Scotland.
Pandemic Impact on Suicide, Self Harm and Suicidal Thoughts
While data on suicide rates during the pandemic is not yet available, the adverse effects on people with mental illness, and on population mental health in general, are likely to be exacerbated by fear, self-isolation, and physical distancing.
NHS 24 has seen an increase in calls, including to Breathing Space, since the beginning of the pandemic. Loneliness and isolation has been one of the most common caller issues raised in contacts to Samaritans, with volunteers noting a large increase in the number of times this is talked about since the start of the pandemic. The most common concerns of callers to the Samaritans explicitly related to COVID-19 are loneliness and/or isolation, mental health and illness, family, and finance and unemployment. Recent survey work for the Mental Health Foundation reports that one in four adults in Scotland have felt lonely because of the pandemic.
There is anecdotal evidence, in the UK, 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.
Pandemic Impact on Scotland’s Suicide Prevention Action Plan
The Scottish Government’s three year Suicide Prevention Action Plan (SPAP) continues to be supported by the NSPLG. The refocussing of some stakeholder resources away from this work onto other immediate pandemic response has led to the following areas of work being prioritised:
Action 2 — mental health and suicide prevention training
Action 3 — public awareness campaigns
Action 5 — models of crisis support
Action 6 — innovations in digital technology
Action 9 — data, evidence, monitoring and guidance.
Work on the other actions in the SPAP is being paused or adapted as necessary, within current resource constraints. The NSPLG Lived Experience Panel has adopted remote working methods to continue its work as far as it can. The NSPLG Academic Advisory Group (AAG) is actively involved in pandemic-related research and impact monitoring, and participates in the Scottish Government’s Mental Health Research Advisory Group.
In order to identify additional areas of priority and make appropriate recommendations to stakeholders, the NSPLG has adopted a paper on suicide risk and COVID-19 produced by the COVID-19 Suicide Prevention Research Collaboration (including the co-chairs of the AAG) and recently published in the Lancet Psychiatry. The NSPLG is using the interventions set out in that paper as a basis for recommending evidence-based responses to promote suicide prevention during the pandemic. (See appendix A.)
Recommendation: Priorities for Pandemic-Related Suicide Prevention Action
It is clear that specific policy areas beyond mental health, such as equalities, employment and the economy, will need to be engaged to address the potential mental health and suicide consequences of the pandemic. The evidence-based interventions identified by the COVID-19 Suicide Prevention Research Collaboration in its Lancet Psychiatry paper provide a basis for a pandemic-specific plan of action for suicide prevention in Scotland as we move through the stages of the pandemic.
The key suicide prevention priorities recommended by the NSPLG for action in the current stage of the pandemic are:
1. Closer national and local monitoring of enhanced and real time suicide and self-harm data — to identify emerging trends and groups at risk for early preventative action
2. Specific public suicide prevention campaigns, distinct from and in partnership with the umbrella ‘Clear Your Head’ mental health and wellbeing campaign — to encourage people at risk of suicide and in suicidal crisis to seek help without stigma and to encourage others to give it
3. Enhanced focus on specifically suicidal crisis intervention — to ensure that those in suicidal crisis can access timely help and support, and meet any increase in numbers
4. Restricting access to means of suicide — to reduce the availability to those in crisis of the most commonly used means of suicide
Public Health Scotland and Suicide Prevention
The creation of Public Health Scotland, with its core commitment to collaborative leadership and its place at the heart of national pandemic health response, provides a timely opportunity to help strengthen local leadership on suicide prevention. It provides the means for embedding an improvement approach to suicide prevention through a virtuous cycle of engagement, creativity and experimentation, planning, evidence and review.
The NSPLG is keen to work with Public Health Scotland to help build and support sustainable local leadership. Prior to the pandemic, the NSPLG and Public Health Scotland had begun discussions exploring opportunities to work together on making suicide prevention everyone’s public health business. This partnership will continue, building on the relationships developed by national and local pandemic responses.
Recommendation: A Long Term Broad-Based Suicide Prevention Strategy
Scotland’s current three-year Suicide Prevention Action Plan contains actions which are being prioritised in the context of the pandemic. These should now be supplemented by promoting the evidence-based suicide prevention interventions set out by the COVID-19 Suicide Prevention Research Collaboration in its Lancet Psychiatry paper. Most important at the current stage of the COVID-19 pandemic are the four priorities identified in this report for immediate action. However, even before the advent of the pandemic the NSPLG had reached the conclusion that more can be done with even more ambition in a longer-term suicide prevention strategy for Scotland, following on from the current three year plan.
Looking beyond mental health to the specific drivers for suicide of isolation, entrapment, loneliness and financial stress is the next stage in the evolution of Scotland’s longstanding focus on suicide prevention and is now made more pressing by the potential long term impacts of COVID-19.
The Scottish Government, COSLA and its member local authorities are already taking approaches in many areas of social policy that will contribute to suicide prevention. However, there is a need to specify and replicate such approaches and provide support to embed them nationally and locally.
The NSPLG recommends that a longer-term — potentially 10 year — suicide prevention strategy for Scotland should build on the current Suicide Prevention Action Plan and the learning from multi-agency pandemic mental health responses. This is a logical and necessary step from where we are now and should support the recovery phase of the national pandemic response. Scotland’s long term suicide prevention strategy should be supported by an agreed cross-government (national and local) programme of work and an outcomes-based evaluation framework, with continuing investment.
Should the Scottish Government indicate that it accepts our recommendation to develop in collaboration with COSLA a longer term strategy leading on from the current three year plan, it will be necessary to identify those specific wider policy areas beyond mental health policy which have a role to play in suicide prevention.
We set out below key areas we recommend should be included in a future suicide prevention strategy for Scotland.
A long term suicide prevention strategy should help to develop understanding of critical issues, including the drivers for unscheduled care presentations; the wider links between suicide and inequalities, deprivation, social security, employment, criminal justice/prisons; the relationship between suicide and self-harm; and the stigma which still surrounds suicide.
A long term suicide prevention strategy should include support for addressing the often-revolving door of suicidal crisis and optimising local knowledge and planning to ‘suicide proof’ locations of concern, should aim to continue to decrease general access to means of suicide (‘means restriction’), and should encourage responsible media reporting.
Addressing the detrimental and potentially long-lasting effects of misuse of social media as well as addressing issues related to online harms and harmful content are essential features of a future suicide prevention strategy. As are the involvement of schools and communities in ensuring that support and education about mental wellbeing and suicide prevention are available for all children and young people.
The National Suicide Prevention Leadership Group makes this statement on the basis that suicide prevention is and should continue to be an integral part of Scotland’s COVID-19 pandemic public health response and recovery phases.
Firstly, we wholeheartedly welcome the initiatives developed and resourced by national and local government and the third sector to support the mental health of people across Scotland during the pandemic, because these will help to save lives from suicide.
Secondly, we identify the importance of adding to these initiatives through certain aspects of Scotland’s Suicide Prevention Action Plan, combining these with promoting the pandemic-specific evidence-based interventions identified in the Lancet Psychiatry article referenced here, and immediately prioritising four specific interventions.
Finally, we recommend building on the dual foundations of the current three year Action Plan and the new pandemic responses to develop a broad, long term, outcomes-based and evaluated suicide prevention strategy for Scotland.
Now more than ever we must both take effective immediate action to prevent the loss of life through suicide in Scotland and also mitigate through an effective long term suicide prevention strategy the potential far-reaching consequences of the COVID-19 pandemic.