Suicidal thoughts, suicide attempts and self-harm

Full text

Suicidal thoughts, suicide attempts,
and self-harm
Sally McManus | Angela Hassiotis | Rachel Jenkins | Mick Dennis | Camille Aznar | Louis Appleby
ADULT PSYCHIATRIC MORBIDITY SURVEY 2014 CHAPTER 12

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Summary
• Suicide prevention is a major goal for local authorities and central government.
Between 2007 and 2013, suicide registration data showed a broadly upward
trend among men and stability among women, although in 2014 and 2015 the
male rate declined and the female rate increased.
• Self-reported suicidal thoughts, suicide attempts and self-harming (without
suicidal intent) are associated with great distress for the people who engage in
them, as well as for the people around them. They are strongly associated with
mental illness, and help to identify people at increased risk of taking their own
lifein the future.
• The Adult Psychiatric Morbidity Survey (APMS) included questions on these in
both the face to face and the self-completion parts of the interview. For reasons
of comparability, trends over time draw on face to face reports, which tend to be
lower. A variable combining face to face and self-completion data was used for
examining differences in rates between groups.
• The proportion of the population who reported having self-harmed increased
from 2.4% and 3.8% of 16 to 74 year olds in 2000 and 2007, to 6.4% in 2014.
This increase is evident in both men and women and across age-groups. Greater
awareness of self-harming is probably a factor in the increased reporting.
• One in four 16 to 24 year old women (25.7%) reported having self-harmed at
somepoint; about twice the rate for men in this age group (9.7%) and women
aged 25 to 34 (13.2%). The gap between young men and young womenhas
grown over time.
• Self-harm in young women mostly took the form of self-cutting. The majority
reported that they did not seek professional help afterwards.
• In 2014, 5.4% of 16 to 74 year olds reported suicidal thoughts in the past
year, asignificant increase on the 3.8% reporting this in 2000. For women, the
increase occurred between 2000 and 2007; for men it took place later, between
2007 and2014.

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• Since 2000 there has been a slight increase in the reporting of suicide attempts,
butonly among women (0.5% in 2000, 1.0% in 2007).
• Particular subgroups have experienced more pronounced increases over time. For
example, people aged 55 to 64 suicidal thoughts (2.1% in 2000; 4.9% in 2014)
and suicide attempts (0.1% in 2000; 0.6% in 2014) at least doubled in rate
since2000. This was evident both in men and women.
• Some groups in the population were more likely than others to report these
thoughts and behaviours, such as those who lived alone or were out of work
(either unemployed or economically inactive). Benefit status identified people at
particularly high risk: two-thirds of Employment and Support Allowance (ESA)
recipients had suicidal thoughts (66.4%) and approaching half (43.2%) had
madea suicide attempt at some point.
• Overall, half of people who attempted suicide sought help after their most
recent attempt (50.1%). About a quarter sought help from a GP, a quarter went
to a hospital or specialist medical or psychiatric service, and a fifth tried to get
help from friends or family.
• Men and women were equally likely to seek help after a suicide attempt.
Olderpeople were more likely to seek help from a hospital or specialist medical
or psychiatric service than younger people; the latter were more likely to turn to
family and friends. Using GPs as a source of support following a suicide attempt
was equally common across age-groups.
12.1 Introduction
In 2015, England’s Department of Health (DH) published its second annual
reporton the cross-government outcomes strategy to save lives: Preventing suicide
in England: Two years on (DH 2015). Between 1990 and 2007 the suicide rate in
England fell, and in 2007 reached its lowest recorded level in men (at 13.9 per
100,000). The male suicide rate then saw an upward trend, reaching 16.1 per
100,000 in2013 (a return to about the level it was in 2001) before falling in 2014
and 2015. In 2015 itwas highest in men aged 40 to 59 (ONS 2016). Economic

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and employment context has been identified as a factor in trends in male suicide;
those areas of England worst affected by recent unemployment experienced greater
increases in suicide (Barr et al. 2012). Rates in women are lower and have stayed
relatively constant since 2007, although increasing from 4.3 to 5.0 deaths per
100,000 between 2013 and 2015 (ONS 2016).
Among its key objectives, the English National Suicide Prevention Strategy
includesthe development of epidemiological evidence concerning suicide and
self-harm (DH 2015). Such knowledge is needed to plan services and target
interventions at the most relevant groups. A prior attempt is a key risk factor for
suicide (WHO 2014), and so measuring suicide attempts and self-harm can help
profile people at increased risk of suicide. However, it is important to note that the
relationship between suicidal ideas, self-harm and suicide is not straightforward.
The profile of people reporting suicidal thoughts, attempts and self-harm is very
different, in terms of age and sex, from that of people who take their own life,
andthe great majority of people who engage in these thoughts and behaviours
donot go on to die by suicide.
Suicidal thoughts and suicidal behaviours are, in their own right, associated with
high levels of distress, both for the people engaging in them and in those around
them. They frequently co-occur, but are distinct. While much research on self-harm
has combined suicide attempts with non-suicidal self-harming, Adult Psychiatric
Morbidity Survey (APMS) data can be used to examine these behaviours separately
as it includes some indication of self-reported intention.
Among those who engaged in non-fatal self-harming (with suicidal intent
ornot)many do not consult health services and, if they do, they may not be
identified as being suicidal. Data collected routinely for administrative health
datasets provides a unique understanding of patterns of service use but provides
a different understanding to community prevalence studies. Studies of people
attending health services will be affected by the factors associated with clinic and
hospital attendance (Geulayov et al. 2016). Official statistics on recorded suicides
(official suicides and undetermined deaths) provide a profile of people who have
taken their own life, but not systematically coded detail about their life and
socioeconomic circumstances. While this can be obtained from surveys, survey

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samples exclude those people, mostly male, who take their own life at the first
attempt (Isometsä and Lönnqvist 1998). There is therefore a need to look across a
range of data sources, and at suicidal thoughts and self-harm as well as attempts.
This chapter provides nationally representative estimates of the prevalence of suicidal
thoughts, suicide attempts and self-harm, and trends in these since 2000. Their
relationship to age, sex and other characteristics is described alongside findings
onthe methods and reasons reported for self-harming. Finally, results are presented
onthe help-seeking behaviour of people who have made a suicide attempt, and
onthe types of professional help received by those who have self-harmed.
12.2 Definition and assessment
Suicidal thoughts, suicide attempts and self-harm
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders
(APA 2013) includes two types of self-harming behaviour as conditions for further
study: non-suicidal self-injury (NSSI) and suicidal behaviour disorder (SBD). While
intentionality can be difficult to establish (Kapur et al. 2013), this is broadly the
approach that has also been adopted in the APMS series, with a separate focus on
thinking about suicide; making a suicide attempt with the intention of taking one’s
own life; and harming oneself without the intent to die.
Measuring suicidal thoughts, suicide attempts and self-harm
Face to face questions
As in APMS 2000 and 2007, all participants were asked in the face to face
sectionof the interview a number of questions about suicidal thoughts, suicide
attempts, and self-harm without suicidal intent.1 These questions form part of
the revised Clinical Interview Schedule (CIS-R). For the purposes of the analysis in
this chapter, suicidal thoughts, attempts and self-harm were assessed using the
following questions:
1 These questions were also asked in the 1993 APMS survey, but only of a subgroup of respondents (those who had been depressed
in the previous week). Therefore trends are only presented for 2000, 2007 and 2014.

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• Have you ever thought of taking your life, even though you would not actually
doit?
• Have you ever made an attempt to take your life, by taking an overdose of
tabletsor in some other way?
• Have you ever deliberately harmed yourself in any way but not with the intention
of killing yourself?
A positive response to each was followed up with a question on whether this last
occurred in the past week, the past year, or longer ago.
Self completion questions
While questions about suicidal thoughts, attempts and self-harm were asked
faceto face in order to retain comparability with the previous APMS surveys, it was
recognised that some participants might choose not to report them if asked face
to face. For this reason, in the 2007 and 2014 surveys, some questions were also
asked of all respondents a second time, later in the interview, using laptop self-
completion. In 2007 this consisted of the three lifetime prevalence questions listed
above (a subset of the full section administered face to face). In 2014, most of the
questions on suicidal thoughts, attempts and self-harm were administered in the
self-completion section, with some retained in the face to face section for trends
and for use in scoring the CIS-R.
Questions used for results in this chapter
In 2014, a new question was added on when the participant had last self-
harmed.In previous surveys in the series, participants were asked if they had ever
self-harmed, but not when this had last happened. Trends in self-harm, therefore,
are based only on reports of lifetime experience. Also to retain comparability of
method with the 2000 and 2007 surveys, only data collected in the face to face
interviews were used to assess change over time. The other analyses of suicidal
thoughts, attempts and self-harm in this chapter draw on derived variables
that combine positive responses in the face to face interview with positive
responses inthe self-completion section, as we believe this approach to be

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the most accurate. Generally, reporting in the self-completion was higher than
reportingface to face, but not all participants did the self-completion.
Measuring methods of self-harming
In the self-completion section of the interview, participants who reported that they
had self-harmed at some point were asked which of a list of methods (cutting,
burning, swallowing something, or some other way) they had used. It was possible
to give more than one response.
Did you… (You may give more than one response)
1. Cut yourself
2. Or burn yourself
3. Or swallow anything
4. Or harm yourself some other way
Measuring reasons for self-harming
Participants who reported in the self-completion that they had self-harmed were
also asked two questions about their motivation. It was possible to endorse neither,
one, or both of these reasons:
• Did you do any of these things to draw attention to your situation or to change
your situation?
• Did you do any of these things because it relieved unpleasant feelings of anger,
tension, anxiety or depression?
The issue of intent is very complex; these questions are reductive and the reasons
given by participants for self-harming may reflect subsequent rationalisations
(Kapuret al. 2013). The data presented on this should be treated as only indicative.

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12.3 Results
Suicidal thoughts, suicide attempts and self-harm by age and sex
Prevalence of suicidal thoughts
A fifth of adults (20.6%) reported that they had thought of taking their own life
at some point. If all adults in the wider population had been asked about this it is
likely that the proportion agreeing would be between 19.5% and 21.7% (95%
confidence interval (CI)). This was more common in women (22.4%) than men
(18.7%), and in people of working-age than those aged 65 or more.
The survey questions related to suicidal thoughts across the lifetime. The
higherreporting in people aged less than 65 might be explained by generational
differences, with young people now being more likely to have suicidal thoughts
than their counterparts in the past. However, age group variations in recall,
perception and willingness to report, together with healthy-survivor effects,2
mayexplain some of thisassociation with age.
Figure 12A: Suicidal thoughts ever, by age and sex
Base: all adults
Men Women
%
0
5
10
15
20
25
30
35
40
16–24 25–34 35–44 45–54 55–64 65–74 75+
Age
2 ‘Healthy survivor effect’ is a type of selection bias. People who face adversities on average die younger than those who do not. This
means that those who survive into late old-age will not be representative of their birth-cohort in terms of level of exposure to adversity.

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Prevalence of suicide attempts
One person in fifteen had made a suicide attempt at some point (6.7%, CI 95%:
6.1% to 7.4%). Despite men being more likely than women to take their own
life (ONS 2015), women were more likely to report an attempt (5.4% of men,
compared with 8.0% of women). As for suicidal thoughts, lifetime suicide attempts
were more likely in working-age adults than in those who were older. While the
overall pattern by age was not significantly different in men and women, the rate
of suicide attempts reported by young women (aged 16 to 24) was notably high.
This fits with their particularly high levels of suicidal thoughts, self-harm, and wider
psychiatric morbidity, as captured in other chapters of this report.
Men Women
%
Figure 12B: Suicide attempts ever, by age and sex
Base: all adults
0
2
4
6
8
10
12
14
16–24 25–34 35–44 45–54 55–64 65–74 75+
Age

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Prevalence of self-harm without suicidal intent
The overall rate of self-harm in the adult population (7.3%, CI 95%: 6.7% to
8.0%) was comparable to that for suicide attempt (6.7%), with rates higher in
women (8.9%) than in men (5.7%). However, the age gradient for self-harm was
more pronounced, and this was particularly evident in women. One in four women
aged 16 to 24 (25.7%) report having self-harmed, compared with one in a hundred
women aged 75 or over (0.6%).
Young women were also much more likely than young men to self-harm:
25.7%ofwomen aged 16 to 24 reported this, compared with 9.7% of men in
thesame age group. Such variation by sex was not evident in older age groups.
Table 12.1
Figure 12C: Self-harm without suicidal intent ever, by age and sex
Base: all adults
Men Women
%
0
5
10
15
20
25
30
16–24 25–34 35–44 45–54 55–64 65–74 75+
Age

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Suicidal thoughts, attempts and self-harm; 2000, 2007 and 2014
Note that the trend data in this chapter are based only on face to face reports. In
2007 and 2014 self-completion data on this topic was also collected, this tends to
elicit higher reporting.
Trends in suicidal thoughts
In 2014, 5.4% of 16 to 74 year olds reported suicidal thoughts in the past year
when asked in the face to face part of the interview, asignificant increase on
the 3.8% reporting this face to face in 2000. For women, the increase occurred
between 2000 and 2007; for men it took place later, between 2007 and2014.
Figure 12D: Suicidal thoughts in the past year (reported face to face)
by sex; 2000, 2007 and 2014
Base: adults aged 16–74 and living in England
0
1
2
3
4
5
6
2000 2007 2014
Year
%
Women
Men
Trends in suicide attempts
Between 2007 and 2014, reporting of a suicide attempt in the past year remained
stable at 0.7% of 16 to 74 year olds. Since 2000 there has been a slight increase,
but only among women (0.5% in 2000, 1.0% in 2007).

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Figure 12E: Suicidal thoughts, suicide attempts and self-harm
(reported face to face); 2000, 2007, 2014
Base: adults aged 16–74 and living in England
0
1
2
3
4
5
6
7
2000 2007 2014
Year
%
Self-harm –ever
Suicidal thoughts –
past year
Suicide attempts –
past year
Trends in self-harm
Reporting of lifetime self-harm in the face to face part of the interview has seen
sustained increases over time, from 2.4%in 2000, 3.8% in 2007, to 6.4% in 2014.
This increase is evident across age-groups, in all of which rates have more than
doubled since 2000. In some age-groups (25 to 34 year olds, and those aged 55 to
74) reporting of lifetime self-harm has doubled since 2007.

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Figure 12F: Self-harm ever (reported face to face)
by age; 2000, 2007 and 2014
Base: adults aged 16–74 and living in England
0
2
4
6
8
10
12
14
16
2000 2007 2014
Year
%
25–34 year olds
35–44 year olds
55–64 year olds
65–74 year olds
45–54 year olds
16–24 year olds
Among women aged 16 to 24 years in 2000, one in fifteen reported having ever
self-harmed (6.5%); this increased to one in nine in 2007 (11.7%) and to one in five
in 2014 (19.7%). In 2000, rates of self-harm were similar in young men and women.
By 2014, young women were more than twice as likely to report it as their male
counterparts (19.7%, compared with 7.9% of 16 to 24 year old men). Table 12.2

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Variation in suicidal thoughts, attempts and self-harm
byothercharacteristics
Ethnic group
Lifetime suicidal thoughts, attempts and self-harm were evident across all ethnic
groups. Rates did not differ significantly by ethnic group after age-standardising
the data. It should be noted however, that due to sample size limitations the ethnic
group categories are both small and heterogeneous. It is possible that this might
mask real differences. Table 12.3
Figure 12G: Self-harm ever by sex among 16-24 year olds;
2000, 2007 and 2014
Base: adults aged 16–24 and living in England
%Women
Men
0
2
4
6
8
10
12
14
16
18
20
2000 2007 2014
Year

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Household type
People under 60 who lived on their own were more likely to have suicidal
thoughtsthan those of the same age living with others. This was also true of
having made a suicide attempt and of having self-harmed. Of people living in such
circumstances, 40.2% had suicidal thoughts, compared with 24.8% of people who
lived with another adult. This pattern was also evident in people aged 60 and over:
those living alone were more than twice as likely to have made a suicide attempt
asthose living with another person (6.4%, compared with 2.5%). Table 12.4
Figure 12H: Suicidal thoughts ever, by household type and sex
Base: all adults
%
Men Women
0
5
10
15
20
25
30
35
40
45
1 adult
16–59,
no child
2 adults
16–59,
no child
Small family Large family Large adult
household
2 adults
one or both
60+, no child
1 adult 60+,
no child
Household type

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Employment status
Employment status was associated with suicidal thoughts, attempts and self-harm
in the working-age population (16 to 64 year olds). Among men, the associations
were strong, with rates of each lowest among the employed and highest in the
economically inactive. In women the differences were less marked, with similar rates
in the unemployed and those who were economically inactive. Table 12.5
Benefit status
Age-standardised associations of suicidal thoughts and attempts, and self-harm
with the receipt of out-of-work benefits were examined for people aged 16 to 64.
Links with housing benefits are reported for the whole population.
Two thirds of people in receipt of Employment and Support Allowance (ESA)
(66.4%) had thought about taking their life, approaching half had made a suicide
attempt (43.2%), and a third reported self-harming (33.5%); indicating that this is
a population in great need of support. People in receipt of other benefits also had
Figure 12I: Suicide attempt ever, by employment status (age-standardised)
Base: aged 16–64
%
Men Women
0
5
10
15
20
25
Employed Unemployed Economically inactive
Employment status

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higher rates of suicidal thoughts, suicide attempts and self-harm than those who
did not receive these benefits. Table 12.6
Region
Suicidal thoughts, suicide attempts, and self-harm occur in all regions of England,
without significant variation in rate. This remained the case when the data were
age-standardised to adjust for age-differences in the population of different regions.
Tab le 12 .7
Mental health
As described in Chapter 2, symptoms of common mental disorder (CMD) in the
past week were assessed using the CIS-R. Thetotal CIS-R symptom score was
strongly associated with lifetime suicidal thoughts, suicide attempts, and self-harm.
%
Figure 12J: Suicidal thoughts, suicide attempts, and self-harm ever
by receipt of Employment and Support Allowance (age-standardised)
Base: adults aged 16–64
0
10
20
30
40
50
60
70
ESA recipient Not ESA recipent
Benefit status
Suicidal thoughts Suicide attempts Self-harm

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Two-thirds of people with severe symptoms of CMD (CIS-R score 18+) (65.9%) had
thought about taking their own life, compared with a tenth of those with no or few
symptoms (10.7%). The association was stronger for men than for women.
Table12.8
Methods of self-harming
Overall, three-quarters of people who self-harmed had cut themselves (73.1%);
around one in ten had burned themselves (10.2%); a similar proportion swallowed
something (13.8%); and nearly a third had used some other method (29.1%).
While women were more likely than men to report cutting (77.0%, compared
with66.2% of men), men were more likely than women to have burned
themselves(16.8%, compared with 6.5% of women).
%
Figure 12K: Suicidal thoughts, suicide attempts, and self-harm ever
by severity of symptoms of CMD in the past week (CIS-R score)
Base: all adults
Suicidal thoughts Suicide attempts Self-harm
0
10
20
30
40
50
60
70
0–5 6–11 12–17 18+
CIS-R score

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Methods of self-harming also varied with age (although caution in interpretation
is required; there were only 55 people in the sample aged 55 and over who
reported self-harm). Young people (16 to 34 years) were more likely than their older
counterparts to report cutting or burning themselves, whereas older people were
more likely to report swallowing something or some other method. It was also more
common for 18 to 34 year olds to report more than one method, compared with
those aged 35 or more. Tables 12.9 and 12.10
Figure 12L: Method of self-harming, by age
Base: adults who had ever self-harmed
%
0
10
20
30
40
50
60
70
80
90
16–34 years 35–54 years 55+ years
Age
Cut self Burned self Swallowed something Other way
Reported reasons for self-harming
Three-quarters of people who had self-harmed cited relieving unpleasant
feelingsofanger, tension, anxiety or depression as a reason for doing so (76.7%),
while a third reported self-harming in order to draw attention to or to change their
situation (31.0%). Women were more likely than men to agree with at least one of
these reasons.

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There was an association between reasons for self-harming and age. Younger
people were more likely than older people to report that they self-harm in order to
relieve unpleasant feelings, while older people were more likely than younger
people to report self-harming in order to draw attention. Tables 12.9 and 12.10
Help-seeking behaviour
Help-seeking following a suicide attempt
Participants who reported in the self-completion section of the interview that
theyhad made a suicide attempt were asked whether they had sought help
following the most recent attempt. Overall, half reported that they had done so
(50.1%). About a quarter of people sought help from a GP (26.4%), a quarter went
to a hospital or specialist medical or psychiatric service (25.5%), and a fifth tried to
get help from friends or family (21.7%). Very few mentioned other sources (1.8%).
%
Figure 12M: Reasons for self-harming, by age
Base: adults who had ever self-harmed
To draw attention to situation To relieve unpleasant feelings
0
10
20
30
40
50
60
70
80
90
16–34 years 35–54 years 55+ years
Age

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Men and women were equally likely to seek help from each of these sources.
However, there were differences by age-group. Older people were more likely to
seek help from a hospital or specialist medical or psychiatric service than younger
people; the latter were more likely to turn to family and friends. Using GPs as a
source of support was equally common across age-groups. Tables 12.11 and 12.12
%
Figure 12N: Help seeking after most recent suicide attempt, by age
Base: adults who had ever attempted suicide
0
5
10
15
20
25
30
35
16–34 years 35–54 years 55+ years
Age
GPs Specialist medical/psychiatric service or hospital Family and friends
Medical and psychological help for self-harming
37.7% of people who self-harmed received medical or psychological help
afterwards. A third of people who self-harmed reported psychological help (33.1%)
and a quarter received medical attention (24.6%). 62.3% received neither.
Women were more likely than men to receive medical attention (29.2%,
comparedwith 16.2% of men) or psychological help (38.1%, compared with
24.0% of men). There was also an age-gradient: half those aged 55 and over who
had self-harmed obtained medical or psychological help at some point (52.9%),

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compared with a third of those aged 16 to 34 (33.1%). It should be noted that this
relates to self-harming and help received at any point; some younger people may
go on to receivesupport in the future. Tables 12.13, 12.14
12.4 Discussion
Two major implications for policy and practice emerge in the findings presented
in this chapter. The first relates to self-harming, particularly self-cutting, in young
women and the second relates to suicide risk among men in midlife.
Young women and self-harm
Over the last fifteen years reporting of self-harm has more than doubled in the
population as a whole; the steep increase is evident in both men and women and
%
Figure 12O: Received medical or psychological help
after self-harming, by age
Base: adults who had ever attempted suicide
Medical Psychological Either medical and/or psychological
0
10
20
30
40
50
60
16–34 years 35–54 years 55+ years
Age

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across ages. In 2000, one in fifteen 16 to 24 year old women reported in the face
to face part of the interview that she had self-harmed (6.5%); this increased to
one in nine in 2007 (11.7%) and one in five in 2014 (19.7%). When asked in the
self-completion part of the interview one in four (25.7%) young women reported
having self-harmed, twice the rate in men of the same age (9.7%) and of women
aged 25 to 34 (13.2%). The great majority of the self-harm reported by young
women involved self-cutting.
It is likely that this increase in reporting is due (at least in part) to changes in reporting
behaviour, that minor self-injury which people had not included as self-harm in
previous surveys has started to be labelled as such. It is also likely that people now
feel more able to disclose self-harm. This might happen if self-harming has become
more normalised and less stigmatised. Improvements in rapport between interviewers
and participants could also elicit higher – and probably more accurate – reporting.
Finally, it is possible that increased reporting of self-harm reflects a real increase in the
behaviour. It is likely that a combination of these factors may be at play.
Evidence from other sources supports the view that there has been some real
increase in self-harming behaviour. The Multicentre Study of Self-harm in England
found an increase in self-injury since 2008 among men and girls presenting
for medical care (Geulayov et al. 2016). Analyses of Hospital Episode Statistics
(HES) have also shown increases in people presenting with self-harm, although
data quality concerns have been raised (Clements 2016). Registration statistics
show that the suicide the rate in 15–19 year olds has risen since 2013 for three
consecutive years, although they still have the lowest rate of any age group (ONS
2016). A growing gap in self-harm rates between young women and young men
is consistent with trends in CMD described in Chapter 2, as well as findings from
the Scottish Health Survey (Knudsen 2016) and other research (Hawton and Harriss
2008). Furthermore, a growing gender gap in mental illness and low wellbeing is
consistent with the increases in rates of mental illness found in girls but not boys
(The Children’s Society 2016; Lessof et al. 2016).
While it cannot be confirmed that the increase in self-harm is real, it may be
appropriate for policy and practice to respond now. This matters because individuals
who start to self-harm when young might adopt the behaviour as a long-term

24 | APMS 2014 | Chapter 12: Suicidal thoughts, suicide attempts, and self-harm | © 2016, Health and Social Care Information Centre
strategy for coping; there is a risk that the behaviour will spread to others; and also
that it may lead in time to a higher suicide rate. There is also a need for responsible
reporting of these figures: the way that this issue is discussed may influence future
suicidal behaviour and risk in young people.3
If there is an upward trend in self-harming, with a particularly high rate in young
women, there needs to be greater understanding of what is driving this. Some cite
bullying on social media as one influence (Daine et al 2013), other sources highlight
low self-esteem and anxiety (The Children’s Society 2016). APMS data indicates
that young people who self-harmed were more likely than older people who did
so to report relieving feelings of anger, tension, anxiety or depression as a reason.
It is important that alternative coping strategies are supported and that the right
help is promoted, made available and accessible, including school-based mental
health promotion programmes. Two-thirds of 16 to 34 year olds who self-harmed
said that they got no medical or psychological support as a result (compared with
around a half of older people). Younger people who made a suicide attempt
described turning to family and friends or their GP. Recognition may be required
ofthe additional burden that an increase in self-harm may mean for primary care,
so thatGPs are able to continue to provide this level of support.
Midlife men and suicide risk
The proportion of men aged 55 to 64 who thought about suicide in the past
year nearly tripled from 1.9% in 2007 to 5.3% in 2014. Other chapters in this
report have identified deterioration in the mental health of this group, including
Chapter 2 on trends in CMD. There was a steep rise in registered suicides among
men in midlife between 2007 and 2014, and they have been highlighted as a
priority in England’s National Suicide Prevention Strategy. The data presented here
supports existing evidence on links between male suicidal behaviour and indicators
of recession (Coope et al. 2014), in particular, being unemployed, economically
inactive, or receiving out-of-work disability benefits. Two-thirds of Employment
and Support Allowance (ESA) recipients reported suicidal thoughts, four in ten
hadmade a suicide attempt, and three in ten had self-harmed.
3 For advice on the responsible reporting of suicide, see these guidelines produced by the Samaritans: www.samaritans.org/media-
centre/media-guidelines-reporting-suicide

25 | APMS 2014 | Chapter 12: Suicidal thoughts, suicide attempts, and self-harm | © 2016, Health and Social Care Information Centre
Data presented here is also consistent with evidence showing that both mental
illness and social context remain powerful risk factors for suicidal behaviour and
self-harm. Two-thirds of people with severe CMD (CIS-R score of 18 or more) had
thought about suicide, and people living alone are more likely to have suicidal
thoughts, make a suicide attempt, and to self-harm than those who live with
others. As lone-person households become more prevalent, the mental health
associations with this secular change warrant investigation with longitudinal data.
12.5 Tables
Prevalence and trends
Table 12.1 Prevalence and recency of suicidal thoughts, suicide attempts and
self-harm, by age and sex
Table 12.2 Suicidal thoughts and suicide attempts in the past year and self-harm
ever in 2000, 2007 and 2014 (face to face only), by age andsex
Characteristics
Table 12.3 Lifetime suicidal thoughts, suicide attempts and self-harm
(observed and age-standardised), by ethnic group and sex
Table 12.4 Lifetime suicidal thoughts, suicide attempts and self-harm,
by household type and sex
Table 12.5 Lifetime suicidal thoughts, suicide attempts and self-harm
(age-standardised), by employment status and sex
Table 12.6 Lifetime suicidal thoughts, suicide attempts and self-harm
(age-standardised), by benefit status and sex
Table 12.7 Lifetime suicidal thoughts, suicide attempts and self-harm
(observed and age-standardised), by region and sex
Table 12.8 Lifetime suicidal thoughts, suicide attempts and self-harm, by
severity of current symptoms of common mental disorder and sex

26 | APMS 2014 | Chapter 12: Suicidal thoughts, suicide attempts, and self-harm | © 2016, Health and Social Care Information Centre
Methods and reasons
Table 12.9 Methods and reasons for self-harming, by sex
Table 12.10 Methods and reasons for self-harming, by age
Treatment, service use and help seeking
Table 12.11 Sources sought help from following last suicide attempt, by sex
Table 12.12 Sources sought help from following last suicide attempt, by age
Table 12.13 Whether received medical and/or psychological help after self-harm,
by sex
Table 12.14 Whether received medical and/or psychological help after self-harm,
by age
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This chapter should be cited as:
McManus S, Hassiotis A, Jenkins R, Dennis M, Aznar C, Appleby L. (2016)
‘Chapter 12: suicidal thoughts, suicide attempts and self-harm,’ in McManusS,
Bebbington P, Jenkins R, Brugha T. (eds) Mental health and wellbeing in
England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital.
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