Guidance

3. Mental health: population factors

Updated 25 October 2019

© Crown copyright 2019

This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gov.uk.

Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

This publication is available at https://www.gov.uk/government/publications/better-mental-health-jsna-toolkit/3-understanding-people

1. Introduction

The purpose of the mental health and wellbeing JSNA toolkit is to support people developing the mental health and wellbeing content of their local joint strategic needs assessment. This chapter helps consider factors related to the promotion of mental wellbeing and the prevention of mental health problems. It provides easy access to nationally available topic focused information, guidance and knowledge. The chapter text aims to be plain English and ready to be cut and pasted. The numerous links to external sites should all be current, relevant, and provide access to material that contributes to the JSNA process.

Understanding the local population is vital for good needs assessment and service planning. The characteristics of the local relevant population (for example, size, age and gender) should be known, including how this drives demand for mental health services now and in the future. Specific groups of people should be identified who are at risk of developing, or likely to have, mental health problems and who may benefit from targeted action for prevention and to ensure their needs are met.

To identify inequalities in prevalence of mental health problems, access to services and outcomes it can be helpful to look at population sub-groups. This segmentation looks at difference by gender, ethnicity and other ‘protected characteristics’ as defined by the Equality Act[footnote 1]. Understanding how people with such characteristics experience different levels of mental health problems to the general population will add context to any variation identified. Segmentation can also consider differences by geography and variation in exposure to social ‘place’ effects covered in Mental health: environmental factors.

Alongside mental health across the life-course (documents 4 to 7), there are important causes and consequences of mental health problems worth considering for the local population in terms of health improvement and prevention. These include health behaviours such as smoking, physical activity and misuse of alcohol and drugs. The inter-relationship between mental and physical health is important. Poor physical health increases the risk of developing mental health problems, and vice versa. Mental health problems are common in people with longer-term conditions such as cardiovascular, respiratory and liver diseases, cancer and chronic pain.

People with mental health problems, particularly those who do not access treatment early and with more severe conditions, experience poorer physical health and reduced life expectancy. One measure of local population vulnerability is the level of self-harm across the life-course. While not mental health outcomes in themselves, suicide and self-harm are closely related to factors associated with mental health.

Questions that a JSNA might address, based on the JSNA data inventory:

  • what different populations should be considered when commissioning mental health services?
  • how is the population changing? What will it look like in 5 and 10 years?
  • what is the level of life satisfaction and happiness scores in the different local populations?
  • what is the level of understanding about how to develop positive mental health and wellbeing in this population?
  • how many people have complex or additional mental health needs?
  • what are the main social, and physical and mental health inequalities in the area?
  • what are the local rates of safeguarding and crime prevention?
  • how do health behaviours affect mental health and wellbeing in this population?
  • what are the physical health needs of people with mental illness?
  • what are the mental health needs of people with physical health conditions - are they being recognised and met?
  • are preventive measures being provided to those who need them most?
  • what are the rates of suicide and self-harm and are interventions in place?

2. Population demographics and vulnerable groups

Avoidable, systematic inequalities between groups are unfair. Action can be taken to reduce these[footnote 3]. Some people experience several complex interrelated issues, and many will fall into more than one subgroup. Local areas should have their own knowledge of vulnerable or marginalized groups and perspectives on local equality issues.

2.1 Overview

The age and gender structure of the local population is a important driver of health need and demand for health services. Allocation of NHS resources for mental health (including dementia) is based on modelling mental health condition prevalence against known factors, such as acute mental health need being greatest among working age adults and dementia being more prevalent among older age groups[footnote 4]. Some further weighting is included for ethnicity and socio-demographic factors.

Some subgroups are more exposed and vulnerable to unfavourable social, economic, and environmental circumstances. These subgroups, interrelated with ethnicity, gender and age, are at higher risk of mental health problems. The following groups are identified as being of high risk of mental health problems:[footnote 5], [footnote 6]

  • black and minority ethnic groups (BAME) (see ‘equity of access’ chapter)
  • people living with physical disabilities
  • people living with learning disabilities
  • people with alcohol and/or drug dependence
  • prison population, offenders and victims of crime (see ‘crime, safety and violence’ in Mental health: environmental factors)
  • LGBT (lesbian, gay, bisexual and transgender) people
  • carers
  • people with sensory impairment
  • homeless people (see ‘housing and homelessness’ in ‘Mental health: environmental factors’)
  • refugees, asylum seekers and stateless person

High rates of people moving home within and between areas can disrupt social ties and community networks and is related to higher levels of stress and mental health problems[footnote 7]. This can include people in life transitions such as students. People who have recently arrived from abroad to live in an area may face barriers to accessing mental health services.

People who do not speak English well might need specific help to enable them to access the mental health services. Refugees are more likely to have experienced trauma and have higher prevalence of mental health conditions such as post-traumatic stress disorder (PTSD), depression and anxiety[footnote 8].

Other examples of high risk groups are highlighted in Mental health: environmental factors. In particular, higher rates of mental health problems are associated with poverty and socio-economic disadvantage. Across the life-course (documents 4 to 7), examples of groups identified as high priority are:

  • women who are pregnant or have a child aged under 12 months
  • children living at a socio-economic disadvantage
  • children with parents who have mental health or substance misuse problems
  • looked-after children
  • adults with a history of violence of abuse
  • people with poor physical health
  • older people living in care homes
  • isolated older people

2.2 Data sources

It is expected that demographic profiling of local populations has been undertaken elsewhere in the wider JSNA process. Important sources of demographic data include:

2.3 Local data

Local authorities will hold population and demographic data and may have additional local information on specific at-risk groups based on local data collection and surveys. There is likely to be a lack of data about some groups, due to it not being collated nationally.

2.4 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

3. Equity of access (with particular focus on ethnicity)

Social characteristics, such as gender, disability, age, race and ethnicity, sexual orientation and cultural attitudes influence access to support and services.

3.1 Overview

It is a legal requirement that access to mental health services should not be discriminatory on the basis of protected characteristics as defined by the Equality Act 2010. Protected characteristics are:

  • age
  • disability
  • gender reassignment
  • marriage/civil partnership
  • pregnancy
  • race
  • religion or belief
  • sex
  • sexual orientation

For instance, the needs of older people not being adequately considered when planning mental health services would potentially be considered discrimination.

It is also illegal to discriminate directly or indirectly against people with mental illness in public services and functions. Mental illness is defined as a disability characteristic if the ‘mental impairment has a substantial and long-term adverse effect on a person’s ability to carry out normal day to day activities. [footnote 1]

Research and equalities policy has given significant attention to the disparities in access to, and experience of, mental health services according to ethnicity. People from black and minority ethnic (BAME) groups living in the UK are more likely to[footnote 9]:

  • be diagnosed with a mental health problem
  • seek help in a crisis situation and in A&E
  • be admitted to hospital with a mental health problem
  • experience a poor outcome from treatment
  • disengage from mainstream mental health services

People from black African and Caribbean backgrounds are disproportionately seen in the ‘hard end’ of services (for example, at the point of arrest) and are more likely to receive harsher or more coercive treatments[footnote 10]. Due to the ‘eurocentricity’ of service design, people from some BAME communities struggle to access services in ways meaningful to them[footnote 11].

Following the referendum vote to leave the European Union, some experts have suggested that a culture of extremism and intolerance has become more visible in political debate. Stigma, prejudice and discrimination appear to be on the rise, with examples of racism and assault against migrants and religious and ethnic minorities[footnote 11]. A study based in south east London found that discrimination was associated with higher rates of common mental health conditions, and this effect was strongest for individuals who had recently migrated to the UK[footnote 12].

Detailed consideration of mental illness among BAME groups will require local action. This is likely to include local community engagement work and assessing the use of local support services by ethnic group through direct contact with providers (social care, CQC, advocacy services, specialist mental health, IAPT).

3.2 Data sources

Metrics in the profiling tool relating to ethnicity and equity of access include:

In services:

  • IAPT referrals for BME patients (CCG, STP)

The Severe Mental Illness tool includes proportions by broad ethnic group.

The Adult Psychiatric Morbidity Survey 2014 provides national data on the prevalence of mental health conditions by broad ethnic group. This information can be drawn upon to help understand likely need of particular groups for support in relation to mental health problems and used in conjunction with demographic data to assess equity in uptake and outcome of available care services.

A range of equality indicators are recommended in Understanding local needs for wellbeing data. Data on quality or outcome of services for BAME users is not yet available but may be available locally direct from services.

3.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

Public Health Matters: local action on health inequalities amongst ethnic minorities discusses understanding how ethnicity relates to inequality and health inequality and taking action to reduce ethnicity based inequality.

Race equality foundation and mental health providers forum: better practice in mental health for black and minority ethnic communities gives examples of best practice from organisations and projects promoting and addressing issues around mental health in BAME communities.

Ethnic inequalities in mental health: promoting lasting positive change is a summary of research and analysis in relation to people with a BAME background and mental health. Includes an overview of recent policy developments, headline statistics, and recommendations for action and investment.

Chief Medical Officer annual report: public mental health includes chapters on parity of esteem and on ethnic inequalities and social inclusion.

IAPT positive practice guides aim to increase access across the age spectrum and to meet the needs of diverse and underrepresented groups.

4. Smoking and health behaviours

Positive health behaviours, such as not smoking, eating healthy food, and engaging in physical activity, can encourage psychological wellbeing, improve physical health, prevent mental health problems, and support recovery among people who are unwell. In addition to supporting individuals to make healthy choices, interventions should focus on providing environments which support adopting healthy behaviours.

4.1 Overview

Smoking remains the single biggest cause of preventable death and illness in England. Smoking prevalence is higher among people with mental health problems[footnote 14] than the general population (40.5% of people with a serious mental illness compared to 14.9% of the adult population). A third of all tobacco is smoked by people with a mental health condition.[footnote 15] Smoking among those with a mental health condition has changed little over the past 20 years, in contrast to the marked decline in smoking prevalence in the general population.[footnote 16]

Alongside smoking, there are a number of other links between health behaviours and mental health problems:[footnote 17]

  • mental health problems in childhood predict unhealthy choices in adolescence
  • eating healthy food, particularly fruit and vegetables, can positively affect mental as well as physical health
  • physical activity can positively affect stress, self-esteem, anxiety, dementia and depression and is recommended in the treatment of depression[footnote 18]
  • rates of obesity are higher among people with a mental health condition

Health behaviour, physical health and mental health are closely related. Each is a determinant and consequence of the other and all are underpinned by wider social factors. Mental health affects risk behaviours, including smoking, alcohol and drug misuse, higher-risk sexual behaviour, lack of exercise, unhealthy eating and obesity.[footnote 19]

Risk behaviours cluster in particular groups. For example, low income and economic deprivation is associated with the 20 to 25% of people in the UK who are obese or smoke. This same population has the highest prevalence of anxiety and depression. Such clustering can lead to greater lifetime risk of mental health problems, as well as social, behavioural, financial, and general health problems.[footnote 19]

Negative health behaviours are contributing causes of poorer physical health among those with mental health problems. It is likely that the high prevalence of smoking accounts for much of the reduction in life expectancy among people with serious mental illness.[footnote 20]

People with mental health problems must have access to ‘stop smoking’ interventions where needed, as well as interventions for physical activity and obesity.[footnote 21]

Evidence has shown smokers are increasingly turning to the use of e-cigarettes to help quit smoking with health experts endorsing e-cigarettes to the more harmful substances produced by smoking tobacco.[footnote 22] As part of the NHS long-term plan, a new universal smoking cessation offer will be offered to long-term users of specialist mental health and learning disability services, with options for smokers to switch to e-cigarettes while in inpatient settings.[footnote 23]

Public health action to support healthy behaviour needs to recognise the wider role of social determinants. People’s behaviour choices are highly influenced by the opportunities and influences within their living environment and social setting. Access to public parks and green space can support people to be physically active.[footnote 24] Ensuring there is access to a diverse range of food in the local area and avoiding high density of hot food takeaway outlets can encourage healthy eating.[footnote 25]

4.2 Data Sources

Metrics in the profiling tool that relate to smoking and health behaviours are listed below.

In risk factors:

  • 3 or more risky behaviours in 15 year olds (county and UA)
  • smoking prevalence in adults (county and UA, district and UA, CCG, region)
  • smoking prevalence in adults with depression and anxiety (county and UA, district and UA, region)
  • smoking prevalence in adults with long term mental health conditions (county and UA, district and UA, region)
  • excess weight in adults (county and UA, district and UA, region)

In protective factors:

  • enough physical activity (county and UA, district and UA)
  • use of outdoor space for exercise/health (county and UA)

Other important data sources include:

Local data

Local areas may focus on access to, uptake and outcomes of health behaviour interventions for people with a mental illness and who smoke, and data on these local services will be an important element of the JSNA.

4.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

ASH’s The stolen years sets out recommendations for how smoking rates for people with a mental health condition could be dramatically reduced.

Mental Health Foundation’s Physical health and mental health includes a summary of the relationship between health behaviours and mental health.

The National Institute for Health and Care Excellence (NICE) guidance Smoking: acute, maternity and mental health services aims to support smoking cessation, temporary abstinence from smoking and smoke free policies in all secondary care settings, including mental health services. Includes interactive pathway, baseline assessment, implementation advice and self-assessment tool.

PHE’s Smoking cessation in secondary care: mental health settings provides guidance and self-assessment framework for NHS mental health trusts to develop local action to reduce smoking prevalence and the use of tobacco.

National Centre for Smoking Cessation and Training (NCSCT)’s Smoking cessation and smokefree advice including mental health provides support, guidance and advice on smoking cessation and smokefree policies, including a number of briefings specific to mental health.

PHE’s Vaping in England: an evidence update provides the latest evidence on the prevalence of vaping in adults and young people and the use of e-cigarettes in stop-smoking services.

UK Faculty of Public Health’s Better mental health for all – relationship with physical health and healthy lifestyles provides evidence and information about the links between physical health, mental health and healthy lifestyles.

5. Alcohol misuse and drugs

Harmful use of alcohol or drugs often contributes to or co-exists with mental health problems and leads to poorer outcomes. When people have co-existing conditions it is important that they access relevant treatment in line with NICE and other national guidance. They should not be excluded based on mental health or alcohol/drug use conditions that they may have (‘no wrong door’ principle). It is important that people experiencing mental health crisis are not turned away from services due to intoxication.

5.1 Overview

People with co-occurring mental health and alcohol/drug use conditions often have multiple needs, with poor physical health alongside social issues such as debt, unemployment or housing problems. They are also more likely to be admitted to hospital, to self-harm, or die by suicide[footnote 26].

Alcohol is the third leading preventable cause of ill health after tobacco and hypertension[footnote 6], and in England, among people aged 15 to 49 years, it is the leading cause of ill-health, and disability [footnote 27].

Drinking more than the low risk guidelines can harm mental and physical health. It can also lead to social problems, such as unemployment, divorce, domestic abuse, and homelessness[footnote 28].

Regular consumption of alcohol has been shown to cause mental ill health including depression, anxiety, and a connection to higher levels of self-harm and suicide in people with alcohol problems[footnote 29]. Regular heavy drinking can also lead to alcohol dependence. The relationship between mental health problems and alcohol is a vicious cycle. Mental health problems can cause people to drink more, particularly as people often drink alcohol as a form of ‘self-medication’.

Drug misuse includes taking illegal drugs and the consumption of controlled prescription drugs, such as benzodiazepines, without a prescription. Estimates suggest that 2.7 million adults took illicit drug in the last year[footnote 30].

Research shows that mental health problems are experienced by the majority of drug (70%) and alcohol (86%) users in community substance misuse treatment.[footnote 31] 41% of people entering community alcohol and drug treatment in 2017 to 2018 reported a co-occurring mental health treatment need.[footnote 32] There are many factors associated with harmful alcohol and drug use. Drug misuse can cause social disadvantage, and social disadvantage may lead to drug use and dependence. Many are social factors, such as deprivation. Drug use and misuse tend to be clustered. For example, areas of relatively high social deprivation have a higher prevalence of illicit opiate and crack cocaine use and larger numbers of people in treatment.[footnote 33] [footnote 34] These also relate to mental health as discussed in Mental health: environmental factors.

The risk of alcohol and/or drug misuse are highest amongst people experiencing severe or multiple disadvantages.[footnote 35] For example, over half of all deaths of homeless people in 2017 were due to alcohol, drugs, or suicide; with drug poisoning alone making up to 32% of the total deaths.[footnote 36] Prevention and treatment interventions aiming to influence and treat drug and alcohol misuse should therefore consider the root causes of health and social harms. They must aim for broader interventions on the social determinants.

Alcohol and drug misuse contributes to wider social harms such as:[footnote 6]

  • absenteeism
  • unemployment
  • domestic violence
  • family breakdown
  • child maltreatment
  • public disorder

There are many links between substance misuse and crime. This includes gang violence and crimes such as theft, burglary, fraud and shoplifting. Victims believed the perpetrator(s) to be under the influence of alcohol in 39% of violent incidents, while 21% of the perpetrator(s) were believed to be under the influence of drugs.[footnote 37] Drunkenness is associated with a majority of murders, manslaughters and stabbings and half of domestic assaults.[footnote 38]

While there may be public perception of a relationship between violent crime and serious mental illness[footnote 39], between 2006 and 2016 11% of homicide convictions in the UK were known to be committed by mental health patients[footnote 40]. Research suggests that substance misuse and socio-economic factors play a far more important role[footnote 41].

NICE recommends that staff in mental health settings should routinely carry out alcohol screening and ask service users about recent legal and illicit drug use, including type, method of administration, quantity and frequency. They should provide brief interventions, harm reduction information and signpost to specialist services. NICE guidance for people with coexisting severe mental illness[footnote 42] and substance misuse outlines best practice which includes adapting existing secondary care mental health services to meet both a person’s co-occurring severe mental illness and substance misuse needs and focusing on their wider health and social care needs. It is important to provide coordinated services that address their wider health and social care needs as well as other issues such as employment and housing. Empathy and respect are vital as people with co-occurring conditions are often stereotyped and stigmatized[footnote 30].

NHS England is leading work to redesign and reorganise core community mental health teams into a new community-based offer that will include access to psychological therapies, improved physical health care, employment support, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use.

5.2 Data sources

Metrics in the profiling tool that relate to alcohol misuse and drugs

In risk factors:

  • admission episodes for alcohol-related conditions (county and UA, district and UA)
  • 3 or more risky behaviours in 15 year olds (county and UA)
  • estimated prevalence of opiate and/or crack cocaine use (county and UA)

In services:

  • admission to hospital for mental and behavioural disorders due to alcohol (county and UA, district and UA )
  • concurrent contact with mental health services and substance misuse services for drug misuse (county and UA)
  • concurrent contact with mental health services and substance misuse services for alcohol misuse (county and UA)

Other important data sources include:

5.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

Alcohol Concern’s An audit of the focus on alcohol-related harm in joint strategic needs assessments, joint health and wellbeing strategies and CCG commissioning plans focuses on the priority given to addressing alcohol-related harm in JSNAs, JHWS and Clinical Commissioning Group (CCG) plans across England.

[ NICE’s Coexisting severe mental illness and substance misuse: community health and social care services covers how to improve services for people aged 14 and above who have been diagnosed as having coexisting severe mental illness and substance misuse. The aim is to provide a range of coordinated services that address people’s wider health and social care needs, as well as other issues such as employment and housing.

PHE’s Better care for people with co-occurring mental health, and alcohol and drug use conditions gives guidance on commissioning and providing better care for people with co-occurring mental health, and alcohol and drug use conditions.

PHE’s JSNA support packs for alcohol, drug and tobacco use will help local areas to develop JSNAs and local joint health and wellbeing strategies, which effectively address public health issues relating to tobacco, drug and alcohol use.

The Joint Commissioning Panel for Mental Health (JCPMH)’s Guidance for commissioners of drugs and alcohol services is based on evidence and developed jointly between professionals and people who use drug and alcohol services.

Turning Point’s Dual diagnosis toolkit is a mental health and substance misuse guide for professionals and practitioners, written to support the development of services for people with co-existing mental health and substance use problems. At the heart of the handbook is a series of case studies showing how particular services have implemented good practice.

6. Comorbidity in mental and physical illness

Mental and physical health is totally linked. Mental health and physical health are both determinants and consequences of each other.

Overview

There is a strong argument that support for physical and mental health should be integrated. There are 4 related challenges:[footnote 43]

  • high rates of mental health conditions among people with long-term physical health problems
  • poor management of ‘medically unexplained symptoms’ which lack an identifiable organic cause
  • reduced life expectancy among people with the most severe mental health conditions, largely attributable to poor physical health
  • limited support for the wider psychological aspects of physical health and illness

On average, men with severe mental health conditions die 20 years earlier, and women die 15 years earlier, than the general population[footnote 19]. Compared with the general population people in contact with specialist mental health services have:[footnote 19]

  • nearly 4 times the rate of deaths from diseases of the respiratory system
  • just over 4 times the rate of deaths from diseases of the digestive system
  • nearly 3 times the rate of deaths from diseases of the circulatory system

Much of the extra burden of poor physical health among those with mental health problems can be explained by health behaviors such as smoking and alcohol (see section 5). Other factors also play a part such as barriers to receiving adequate physical healthcare; less than a third of people with schizophrenia in hospital received the recommended assessment of cardiovascular risk in the previous 12 months[footnote 19].

NHS England is leading work to ensure that it meets the physical health needs of 280,000 more people living with severe mental illness by 2020 to 2021. This will be achieved by increasing early detection and expanding access to evidence based physical care assessment and intervention each year. Collaboration between public health, primary care and secondary care mental health services is crucial to realising this aim. This commitment was reaffirmed in the NHS Long Term Plan pledging £2.3 billion a year by 2023 to 2024 to invest with the ambition to increase the number of people receiving physical health checks.

It is important to also consider the mental health needs of people with long-term physical health problems. Integrated care for physical health should include provision of psychological support, as failure to do so is associated with poorer outcomes and faster disease progression[footnote 43]. People with long term chronic conditions should receive psychological therapy support to improve their recovery[footnote 19].

The close relationship between mental health and physical health is strongly underpinned by the underlying social determinants of health, such as social deprivation. This is an important way in which inequalities are perpetuated[footnote 43] and a broad public health strategy should consider the role of these social determinants for the whole population.

6.1 Data sources

Metrics in the profiling tool relating to comorbidity in mental and physical health

In risk factors:

  • smoking in adults with anxiety or depression (county and UA, district and UA, region)
  • smoking in adults with long term mental health condition (county and UA, district and UA, region)

In quality and outcomes:

  • people with severe mental illness (SMI) who have received the complete physical health checks (CCG, STP)
  • excess under 75 mortality rate in adults with serious mental illness (county and UA)

Other important data sources include:

  • Public Health England’s Return on investment (ROI) toolkit provides assessment of the ROI of interventions to protect the mental health of people with physical health problems
  • Understanding local needs for wellbeing data from the What Works Centre for Wellbeing provides recommended relevant indicators
  • Public Health England’s analysis of the physical health inequalities of people with SMI uses a sample of primary care data to examine differences in prevalence of 10 physical health conditions between the population with SMI aged 15 to 74 years and the general population; it also looks at multi-morbidities between the 2 population groups and analyses health inequalities by age, gender and deprivation

6.2 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

Improving the physical health of adults with severe mental illness: essential actions is a report from the Academy of Royal Medical Colleges and the Royal Colleges of General Practitioners, Nursing, Pathologists, Psychiatrists, Physicians, the Royal Pharmaceutical Society and Public Health England providing recommendations.

NHS Rightcare’s Physical ill health and CVD prevention in people with severe mental illness toolkit was developed in collaboration with Public Health England. This toolkit provides expert practical advice and guidance to support system wide improvement to help improve physical health for people with severe mental illness and reduce health inequalities.

NHS toolkit Improving the physical health of people with a serious mental illness: a practical toolkit includes detailed case studies at pilot sites, short examples and supporting documents.

King’s Fund’s report Bringing together physical and mental health calls for integrated physical and mental healthcare. Provides examples of innovative service models and identifies areas where there is scope for improvement.

NHS England’s report from the independent Mental Health Taskforce Five year forward view for mental health sets out recommendations for the NHS and its arms-length bodies to achieve the ambition of parity of esteem between physical and mental health.

NHS health check best practice guidance underlines the importance of physical health checks for people with severe mental illness.

PHE’s Commissioning cost-effective services for promotion of mental health and wellbeing and prevention of mental ill health includes information on interventions to protect the mental health of people with physical health problems.

PHE’s Wellbeing in mental health: applying all our health gives examples to help healthcare professionals make interventions to encouragephysical health and wellbeing in mental health.

Health Matters: reducing health inequalities in mental illness is a professional resource focusing on some of the actions local areas can take to reduce physical health inequalities experienced by people living with mental health illness.

World Suicide Prevention Day 2019 is a study by the National Cancer Registration and Analysis Service exploring data in the risk of suicide after cancer diagnosis in patients, and the risk between the types of cancers which are considered preventable.

7. Suicide and self harm

Every suicide should be seen as preventable. Gaining an understanding of vulnerability in local populations can aid development of an effective suicide prevention plan. People with a history of self-harm are a high-risk group for suicide.

7.1 Overview

Suicide and self-harm are not mental health problems themselves, but they are linked with mental distress[footnote 5]. Suicide is preventable, yet suicide rates in England have generally increased since 2007. Suicide is the biggest killer of men under 50 as well as a leading cause of death in young people and new mothers. On average, 13 people kill themselves every day. The death of someone by suicide has a devastating effect on families, friends, workplaces, schools and communities, as well as an economic cost[footnote 44].

The cross-government prevention strategy identified 7 important areas for action:[footnote 44]

  • reduce the risk of suicide in high-risk groups
  • tailor approaches to improve mental health in specific groups
  • reduce access to the means of suicide
  • provide better information and support to those bereaved or affected by suicide
  • support the media in taking a sensitive approach to suicide and suicidal behaviour
  • support research, data collection and monitoring
  • reduce rates of self-harm as a major indicator of suicide risk

People with a history of self-harm are a high-risk group and a priority for prevention. Some groups have higher rates of self-harm, including young people, particularly looked after children and care leavers, and lesbian, gay and bisexual people. In a recent survey 22% of 15 year olds said that they had previously self-harmed, with almost 3 times as many girls reporting self-harm than boys[footnote 45].

People who self-harm are at increased risk of suicide; although for many people self-harm is a coping mechanism and not a suicide attempt. Risk of suicide is particularly increased in those repeating self-harm and in those who have used violent/dangerous methods of self-harm[footnote 44].

Other groups identified as high risk for suicide are:

  • young and middle-aged men
  • people in the care of mental health services, including inpatients
  • people in contact with the criminal justice system
  • specific occupational groups, such as doctors, nurses, veterinary workers, farmers and agricultural workers

Local areas should have multi-agency suicide prevention plans in place that contribute to a 10% reduction in suicide nationally by 2020 to 2021. By the beginning of 2019 every local area in England has a multi-agency suicide prevention plan in place or in development[footnote 46]. The NHS Long-Term Plan will continue to make reducing suicides over the next decade as a priority by building on the progress that is already made.

7.2 Data Sources

Metrics relating to suicide and self-harm in the profiling tool

In risk factors:

  • long-term unemployment (county and UA, district)
  • children in need due to family stress (county and UA)
  • children in need due to abuse or neglect (county and UA)

In services:

  • hospital admissions as a result of self-harm (all ages) (county and UA, district and UA, region)
  • hospital admissions as a result of self-harm (standardised admissions ratio) (ward)
  • emergency hospital admissions for intentional self-harm (county and UA, ward)

In quality and outcomes:

  • suicide: age standardised rate (males, all ages) (county and UA, CCG, STP)
  • suicide: age standardised rate (females, all ages) (county and UA, CCG, STP)

Other important data sources include:

  • Suicide Prevention Profile provides a range of metrics at local authority, unitary authority and CCG level to enable local areas to understand their need and benchmark against similar populations

7.3 Local data

Guidance on undertaking a needs assessment is in the local suicide prevention planning guidance, the ‘Making sense of national and local data’ section of the Local suicide prevention planning: a practice resource.

Local authorities may want to add to this information with local demographics such as migrant population figures and protected characteristics as defined in the Equality Act. Information collected for local suicide audits can help understand the demographics and circumstances of those in their area who have died by suicide. Some areas are setting up real time suspected suicide surveillance systems to reduce the time delay in obtaining information.

7.4 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

Local Government Association: Suicide prevention a guide for local authorities is a guide for local councils on their role in suicide prevention, including a range of approaches and case studies to inform decision making.

Multicentre study of self-harm in England is a collaborative research programme between the University of Oxford, University of Manchester and Derbyshire Healthcare NHS Foundation Trust.

National confidential inquiry into suicide and homicide by people with mental illness provides the latest data and makes recommendations for improving clinical practice and service delivery to prevent suicide and reduce risk.

NICE’s Preventing suicide in community and custodial settings is a quality statement around self-harm includes aspects of suicide prevention advice, particularly in the resource section (with particular reference to the use of risk assessments).

NICE’s Self-harm pathway is a useful way to navigate through the stages of life course.

PHE’s Suicide prevention – resources and guidance support local authorities and healthcare professionals to develop a suicide prevention strategy and implement action to reduce suicides and improve support for those bereaved or affected by suicide.

Samaritans’ suicide statistics report provides details of England suicide rates (along with Wales, Scotland and the Republic of Ireland) and helps to understand and interpret suicide statistics.

8. References

  1. Equality Act (2010) ↩ ↩2

  2. WHO, Calouste Gulbenkian Foundation. Social determinants of mental health 2014 ↩

  3. NHS England. Technical guide to determination of revenue allocations to CCGs and commissioning areas for 2016-17 to 2020-21 (2016) ↩ ↩

  4. Mental Health Foundation. Fundamental facts about mental health (2016) ↩ ↩2

  5. Department of Health. Annual report of the Chief Medical Officer 2013 - Public health priorities 2014 ↩ ↩2 ↩3

  6. Joseph Rowntree Foundation. Population turnover and area deprivation 2007 ↩

  7. Vostanis P. Meeting the mental health needs of refugees and asylum seekers. The British Journal of Psychiatry (2014); 204(3):176-7 ↩

  8. Mental Health Foundation website. Black, Asian and minority ethnic communities ↩

  9. Fitzpatrick R, Kumar S, Nkansa-Dwamena O, Thorne L. Ethnic inequalities in mental health: promoting lasting positive change 2014 ↩

  10. Bhui K. Brexit, social division and discrimination: impacts on mortality and mental illness? The British Journal of Psychiatry (2016); 209(2):181-2 ↩ ↩2

  11. Hatch SL, Gazard B, Williams DR, Frissa S, Goodwin L, Team SES, Hotopf M. Discrimination and common mental disorder among migrant and ethnic groups: findings from a South East London community sample. Social Psychiatry and Psychiatric Epidemiology (2016); 51:689-701 ↩

  12. Public Health England Fingertips. Local tobacco control profiles: smoking prevalence in adults ↩

  13. Royal College of Physicians. Smoking and mental health (2013) ↩

  14. Ash. The stolen years 2013 ↩

  15. Faculty of Public Health. Relationship with physical health and healthy lifestyles 2010 ↩

  16. NICE. Depression in adults: recognition and management, Clinical guideline (CG90)(2009) ↩

  17. Royal College of Psychiatrists. No health without public mental health: The case for action (2010) ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  18. Royal College of Psychiatrists. Smoking and mental health: a joint report by the Royal College of Physicians and the Royal College of Psychiatrists 2013 ↩

  19. NHS England. Five year forward view for mental health (2016) ↩

  20. NHS England. Long-term vaping ‘far safer than smoking’ says ‘landmark study’ (2017) ↩

  21. NHS England. NHS Long Term Plan (2019) ↩

  22. House of Commons Communities and Local Government Committee. Public parks (2017) ↩

  23. Public Health England. Health matters: obesity and the food environment. (2017) ↩

  24. Royal College of Psychiatrists. Mental illness, offending and substance misuse 2012 ↩

  25. Institute of Health Metrics. Global burden of disease: data visualizations (2019) ↩

  26. NHS. Alcohol misuse ↩

  27. Royal College of Psychiatrists. Alcohol and depression ↩

  28. NHS Digital. Statistics on drug misuse, England, 2018 (November Update). (2018) ↩ ↩2

  29. Delgadillo J, Godfrey C, Gilbody S, Payne S. Depression, anxiety and comorbid substance use: association patterns in outpatient addictions treatment. Mental Health and Substance Use. 2013 Feb 1;6(1):59-75 ↩

  30. Public Health England. Substance misuse treatment for adults: statistics 2017 to 2018 (2018) ↩

  31. HM Government. Opiate and crack cocaine use: prevalence estimates by local area (2017) ↩

  32. HM Government. The public health burden of alcohol: evidence review (2016) ↩

  33. Lankelly Chase Foundation. Hard Edges: mapping severe and multiple disadvantages in England (2015) ↩

  34. Office for National Statistics. Deaths of homeless people in England and Wales: 2013 to 2017 ↩

  35. Office for National Statistics. The nature of violent crime in England and Wales: year ending March 2018 ↩

  36. Drugwise. How much crime is drug related? ↩

  37. Mind. At risk, yet dismissed: the criminal victimisation of people with mental health problems 2013 ↩

  38. HQIP. National confidential enquiry into suicide and safety in mental health annual report (2018) ↩

  39. Stuart H. Violence and mental illness: an overview. World Psychiatry (2003); 2(2):121-4 ↩

  40. NICE. Coexisting severe mental illness and substance misuse: community health and social care services. NICE guideline (NG58) 2016 ↩

  41. Kings Fund. Bringing together physical and mental health 2016 ↩ ↩2 ↩3

  42. Department of Health. Preventing suicide in England: third progress report of the cross-government outcomes strategy to save lives (2017) ↩ ↩2 ↩3

  43. PHE. Intentional self-harm in adolescence: an analysis of data from the health behaviour in school-aged children (HBSC) survey for England, 2014 ↩

  44. HM Government. Cross-government suicide prevention workplan (2019) ↩

Back to top