With the release of the Adult Psychiatric Morbidity Survey 2014 comes a plethora of data and information.
By Jordan Holbrook: Fresh off the delivery van is the Adult Psychiatric Morbidity Survey (APMS) 2014 and, even after many html-500 errors, broken URLs, links to the older website and the attempts by the NHS to move everything over to the new beta site (as well as a late/difficult to locate upload), we’ve now got a bounty of new information.
The APMS (or National Study of Health and Wellbeing, depending on whom you talk to) is a survey of mental health among adults living in private households in England and runs every seven years. There are several other forms however, I will specifically address the Private Household studies. It is commissioned by the Health and Social Care Information Centre and funded by the Department of Health.
The 2014 edition covers a wide variety of mental health areas:
Common mental disorders
Mental health treatment and service use
Posttraumatic stress disorder
Autism spectrum disorder
Drug use and dependence
Suicidal thoughts, suicide attempts and self-harm
Comorbidity in mental and physical illness
Today, I wish to specifically cover ‘Suicidal thoughts, suicide attempts and self-harm‘; I will give currently known statistics, I will address the new information found in the report and will compare it to what has been found in previous editions.
I will also pay specific attention to what I call ‘The Five Steps of Suicidality’ and will note changes over time as well as gender differences. The Five steps are:
1 – Mental Health, Common Mental Disorders (CMDs)
2 – Self-Harm a
3 – Suicide Ideation
4 – Suicide Attempt(s) b
5 – Suicide Mortality
a – The Diagnostic Statistical Manual (DSM-V) includes two types of Self-Harm relevant to Suicide: non-suicidal self-injury (NSSI) and suicidal behaviour disorder (SBD). Whilst intention is oft difficult to ascertain, the APMS 2014 took the approach to separate thinking about suicide, making a suicide attempt with the intention of taking one’s own life and harming oneself without the intent to die.
b – ‘Suicide Attempt(s)’ can also include ‘Suicide Behaviour(s)’ however, I shall only be specifically addressing ‘making a suicide attempt with the intention of taking one’s own life’ in this step. The difference being that ‘Suicide Behaviour(s)’ includes Suicidal Gestures (reckless behaviours that cause harm and potentially death) and ‘Para-suicide’ (similar to an attempt, yet avoids assigning intention, tends to refer to episodes of self-harm that is survived). As such, both have been considered under ‘Self-Harm’ but no distinction has been made.
I organise the five steps as presented above because they can be considered as predictors for suicide, they do not necessarily form a pathway towards suicide mortality (even if victims do follow this route or even a variation of it). I wish to state that my steps are not to be considered as either an official or even a recommended form of diagnosis, however, they can certainly be considered as warning signs (which goes without saying).
I’ve also excluded analysing extraneous, hard-hitting variables such as ‘life events’ in this post as they are outside the scope of this analysis.
I will slightly touch on ‘Common Mental Disorders’, but only for the purpose of understanding gender differences and because the majority of those who attempt (and complete) suicide have been troubled by some form of mental health at some point in their lives – that is not to say, however, that suffering from a Common Mental Disorder immediately puts someone at risk of suicide.
It is also worth noting the changes in scope and methodology of the four studies, the 2007 and 2014 studies covered England only whereas the 1993 and 2000 studies covered England, Wales and Scotland. The age ranges of participants also differed, the 1993 study had an upper limit of 64, the 2000 study had an upper-limit of 74 and the 2007 and 2014 studies had no upper-limit. All four had a lower-limit of 16 years old.
Another issue is that in face-to-face reports participants often reveal less than they do in self-completion questionnaires, just as there’s also gender differences in the levels of reporting.
Where trends have been drawn, data has been corrected to account for changes in methodology.
Several of the graphs I present in this piece are already themselves available and on show in APMS 2014, I reproduce them here simply because I wish for all the graphs to match artistically. I hope the reader can afford me that liberty.
My workings can be found here:
The key points of this post, using information found within APMS 2014, are as follows:
- Women are 1.57 times more likely than men to suffer from a Common Mental Disorder.
- Women are 1.56 times more likely to self-harm than men.
- Self-cutting is the most common form of self-harm, 73% of those who self-harmed reported self-cutting.
- Men are slightly more likely to suffer suicidal thoughts (5.4% of men compared to 5.3% of women).
- Overall, women are more likely to 1.33 times more likely to make an attempt at suicide.
- Women are more likely to seek help following an attempt (51.9% of women compared to 47.1% of men).
- On average, 1 in 47 male suicide attempts will be fatal and 1 in 196 female suicide attempts will be fatal.
- When making an attempt, men are 4.20 times more likely to suffer a fatality than women.
The Layman and common Joe will probably know by now that in the UK the biggest killer of men under 45 is suicide. In 2014, there were 6,122 suicides of people aged 10 and over registered in the UK, 76% of which were male. For every 4 suicides, 1 will be female and 3 will be male.
The male suicide rate is 16.8 male deaths per 100,000 and the female suicide rate is 5.2 female deaths per 100,000. There are 3.23 times the number of male deaths as female.
There has been an overall reduction in the suicide rate, but this is because of the decrease in the female suicide rate, which has halved since 1981. This occurred between 1981 and 1996, since then it has hovered around 4.7 – 5.8 per 100,000. The male suicide rate, which is much more temperamental, has swung between 15.6 and 21.4 per 100,000 since 1981.
For males, the age range most at risk are those aged 45-59, followed quickly by those aged 30-44 (23.9 per 100,000 and 21.3 per 100,000 respectively). For females, the age range most at risk is also 45 – 59 (7.3 per 100,000).
The most common method employed is hanging, accounting for 55% of male suicides and 42% of female suicides. The second most common is poisoning, accounting for 37% of female suicides and 19% of male suicides. Even despite it being a more common method for women, in terms of absolute numbers, more men died by self-poisoning than women (903 male deaths and 538 female deaths).
Considering this, it is the author’s intention to assess the five steps and to understand the gender differences in suicidality.
Reading APMS 2014 – The Five Steps
1 – Mental Health, Common Mental Disorders (CMDs)
Common Mental Disorders have been on the increase since APMS first started and women suffer around 50% more often than men in all iterations of the study. A Common Mental Disorder (CMD) is defined by APMS as having reached a score of 12 or more on the revised Clinical Interview Schedule (CIS-R) and is comprised of different types of depression and anxiety. To quote: “they cause marked emotional distress and interfere with daily function, but do not usually affect insight or cognition. Although usually less disabling than major psychiatric disorders, their higher prevalence means the cumulative cost of CMDs to society is great.” (A more expansive definition and explanation can be found in Section 2.2 of APMS 2014.) To reiterate, many CMDs have a strong association with suicide, so acknowledging the mental well-being of the nation will give a good view and understanding of the suicide trends of late.
I have compiled graphs below detailing the gender differences and change over time for scores of 12 or more, scores from 12 to 17 and scores of 18 or above. Scores are given based upon past week prior to the study. To quote the significance of the scores:
“CIS-R score of 12 or more is the threshold applied to indicate that a level of CMD symptoms is present such that primary care recognition is warranted.
CIS-R score of 18 or more denotes more severe or pervasive symptoms of a level very likely to warrant intervention such as medication or psychological therapy.”
Several things can be ascertained from the data presented here:
- As prior mentioned, the female CMD rates are consistently higher than male rates.
- The problem is getting worse, not better, more people are reporting CMDs.
- The overall increase seen since 1993 is because of the extreme end, many more people are reporting CIS-R scores of 18+ (whilst scores of 12 – 17 are similar to what we saw 20 years ago).
- The percentage of people reporting a CIS-R score of 12 – 17 is only slightly larger than the percentage of people reporting a CIS-R score of 18 or more.
Whilst the female rates have been consistently higher, comparing the results of APMS 2014 to 1993, there was a larger growth in male rates (of 12 and above) than in female rates; 20.9% increase in female rates compared to 29.5% in male rates. However, in 2014, 1.57 times as many women (to men) reported CIS-R score of 12 or more, 1.60 times as women reported CIS-R score from 12 to 17 and 1.55 times as many women reported CIS-R score of 18 and above. Even despite the growth in male rates, women still lead by at least 50%.
Considering the above, that women suffer CMDs at approximately one and a half times the rate of men and that mental health is strongly associated with suicide, we would expect to see a similar trend in the female suicide mortality rate, but we do not.
2 – Self-Harm
As mentioned just above, women suffer CMDs at approximately 1.5 times the rate as men do and so, in turn, we see that it manifests itself in similar proportions.
The above graph shows that, just like CMDs, women are self-harming 1.56 times as often as men. Just as has been stated in the graph (and earlier in this post), self-harm has been counted for all harm performed without suicidal intent. Survived episodes of self-harm with suicidal intent have been included in ‘Suicide Attempt(s)’.
The most common form of self-harming is self-cutting, 66.2% of male participants and 77% of female participants reported having cut themselves at some point in their lives. Participants could choose more than one answer (true for both questions).
Data above has been re-run for trends, data unavailable for 1993.
What is most interesting about this graph is not just the sudden leap in self-harm but also the sudden leap in gender differences of self-harm. The gender difference is caused because of young women – a staggering 25.7% of women aged 16-24 reported self-harm (compared to the female average of 7.9%). Only 9.7% of men in the same age band reported self-harm.
Male reporting of self-harm continued along a slower growth rate, however, the change in female rates are substantial. Between 2000 and 2007 male rates increased from 2.1% to 3.7% (76% increase) and female rates increased from 2.7% to 3.8% (41% increase). Between 2007 and 2014 male rates increased from 3.7% to 5.0% (35% increase) and female rates increased from 3.8% to 7.9% (108% increase). The change in the female self-harm rate since the previous study is triple that of the change in the male self-harm rate since the previous study.
Overall, women are self-harming 1.56 times as often as men are, although there is little gender differences in methods employed and in reasons for doing so. As such, we would expect the higher female self-harm rate to have an effect on suicide mortality, but as was mentioned at the end of ‘Mental Health – Common Mental Disorders (CMDs)’, the higher female rates do not seem to have an impact on suicide mortality.
3 – Suicide Ideation
As with the previous categories, there’s surprising information to be learned about suicide ideation in England, especially in the gender differences – or in this case, gender similarities.
For the two prior iterations, there has been a gap between the genders with women scoring higher in both studies. However, in APMS 2014 men now score slightly higher than women – 5.4% of men reported having suicidal thoughts in the past year compared to 5.3% of women. In 2007, 3.5% of men reported having suicidal thoughts in the past year compared to 5.5% of women.
The remarkable surge in male suicidal thoughts between 2007 and 2014 is greater than the growth seen in female suicidal thoughts between 2000 and 2007. The female rate grew from 4.2% to 5.5% (22.2% increase) between 2000 and 2007 and the male rate grew from 3.5% to 5.5% (57.1% increase).
In 2014, men are 1.02 times more likely to ideate suicide than women (female rate is 0.96 that of the male rate). This higher male rate does not account for the higher male rate in suicide mortality.
4 – Suicide Attempts
If men are 1.02 times as likely to ideate suicide as women, perhaps they are 1.02 times as likely to attempt suicide?
No, this is not the case. In APMS 2014, 0.6% of men reported attempting suicide in the past year compared to 0.8% of women – women are 33% more likely than men to attempt suicide than women.
This gap is considerably smaller than what it was in 2007, 0.5% of men reported a suicide attempt in the past year compared to 1.0% of women (women 100% more likely to attempt suicide than men).
The surge in male suicidal thoughts is represented here yet the fall in female suicide attempts is larger than the fall in female suicidal thoughts.
In 2014, 5.4% of men reported having suffered suicidal thoughts (in the past year), 5.0% reported having self-harmed (ever) and 0.6% reported a suicide attempt (in the past year).
In 2014, 7.9% of women reported having self-harmed (ever), 5.3% reported having suffered suicidal thoughts (in the past year) and 0.8% reported a suicide attempt (in the past year).
When suffering suicidal thoughts, women are more likely to make an attempt. 15.59% of women who suffered suicidal thoughts made an attempt, 12.06% of men who suffered suicidal thoughts made an attempt. Women with suicidal thoughts are 1.29 times more likely to make an attempt than men with suicidal thoughts.
In 2014, 47.1% of men sought help from at least one source following an attempt compared to 51.9% of women. This is considerably lower for both genders than in 2007, where 63.0% of men and 58% of women sought help from at least one source.
In 2007, men were 1.08 times more likely to seek help than women but in 2014 women sought help 1.1 times more than men.
5 – Suicide Mortality
Let us compare suicide fatalities to suicide attempts so as to find the likelihood of suicide completion. Let’s start by taking four key pieces of information: population size, suicide attempts (as a percentage), estimated number of suicide attempts and registered number of suicide fatalities. Using this information we can assume a suicide completion rate. All data is England only, correct for 2014. Data may not add due to rounding. Sources are APMS 2014, Annual Mid-year Population Estimates and ONS Deaths Registrations for 2014.
|Suicide Attempts (%)||0.6%||0.8%||0.7%|
|Est. No. Attempts||173,208||229,656||402,389|
[Note: ONS records suicide for ages 10 and above whereas APMS records data for 16 and above. This has not been corrected for.]
On average, 1 in 47 male suicide attempts will be fatal and 1 in 194 female suicide attempts will be fatal. The male suicide fatality rate is 4.20 times the size of the female suicide fatality rate.
[Note: The conclusions I draw are not to be taken as valid, there are many variables and factors affecting suicide that have not been taken into consideration here. Such variables include (and are not limited to): a successful first attempt (thus not recorded by APMS), difficulty in ascertaining if a death was an intentional suicide, unreported deaths, data was collected via face-to-face reporting so thus may have suffered lower response rate and other variables. My estimations above are exactly that, estimations.]
Gender Differences in Expected Suicide Risk
Let us compare the rates discussed in the previous 5 steps with the suicide mortality rate.
|Ratio of rates, Women:Men|
From the table above, we can see that women score worse in near all aspects of suicidality (excluding suicide ideation and help-seeking following an attempt, where the differences are coincidentally smallest). Yet, paradoxically, men are dying more from suicide 3.23 times as often. This is known as ‘The Gender Paradox in Suicide’. The Gender Paradox can be explained as the paradox where we expect women to be at greater risk of suicide, yet more men die from suicide than women.
As has been argued, women pose a greater risk for suicide. They suffer Common Mental Disorders more than men. They self-harm more than men. They ideate suicide slightly less than men yet they attempt suicide more than men. Women seek help more often than men (but not by much) and men die from suicide more than women. Suicide attempts prove fatal more often for men despite attempts happening less often. This leaves us with the paradox of gender suicidality. More research is to be done to determine how we can alleviate this paradox and ultimately lower male suicide mortality.