Suicide is the biggest killer of men under the age of 45. Yet people still experience stigma when seeking help for mental illness, despite high-profile discussions of mental health issues such as those by members of the royal family and sportspeople. And a report into the Government’s suicide prevention strategy in March 2017, suggested that although 95% of local authorities now have a suicide prevention plan, there is little or no information about the quality of those plans, or whether adequate funding is available to implement them.

The lack of progress made on improving suicide and general mental health provision has led to a growing frustration among professionals and resulted in attempts to create new approaches to tackle mental health issues, and in particular to improve access to support for people in crisis or at risk of suicide.

The idea of a “zero suicide city” was first adopted in Detroit in the late 2000’s, with others following its lead in subsequent years. With reports finding that around 14 Londoners a week took their own life in 2015 (735 in total), an increase of a third from the 2014 statistics, a report in February 2017 by the London Assembly Health Committee suggested that London too should take this approach.

So what can London, and other areas of the UK, learn from Detroit’s approach? And how can services act to reduce the number of people taking their own lives?

Zero-suicide cities

Poverty and high unemployment in Detroit are contributing factors to high levels of depression among city residents. As a result of these high rates of depression and very high suicide statistics, Detroit-based mental health professionals adopted a new approach to tackle the stigma around mental illness and use identifiers to highlight cases of crisis, or potential crisis. The focus is on preventative care, encouraging professionals to act upon signs of mental illness before a suicide or attempted suicide takes place.

Patients attending health clinics for other illnesses, including diabetes or heart failure, are also now screened for depression and other mental health issues before they are released. This allows people deemed to be ‘at risk’ to be identified as soon as they come into contact with medical professionals, who can then refer the patient to a mental health specialist if needed, rather than reacting to mental illness once it reaches crisis point.

In order to support this approach, a centralised IT system was created which means results are traceable, and surveys and information are standardised so they can be used and accessed across clinics throughout Detroit. Coordination with non-medical practitioners, including social workers, employers and family members, has also been key in identifying people at risk and signposting them to help at every possible opportunity. There has also been additional training for staff to improve recognition of identifying factors. Patients can email their clinicians or liaising staff directly and attend regular drop-in appointments. Up to 12,000 patients using mental health facilities are tracked each year in the city and some statistics suggest that the clinics reduced suicides by over 80%.

There have been some criticisms of the system however, despite the reduction in the number of suicides in the city. Critics highlight the fact that many of the poorest and most severely in need of help are not reached as they do not have health insurance and so do not attend those clinics involved in the scheme.

Ultimately, however, the scheme seeks to provide better preventative, coordinated and targeted care to those who are at risk or show some signs of mental health crisis. And some in the UK have suggested there are lessons that could be learned from this approach.

Whole system approach to suicide prevention in the East of England

Four local areas in the East of England (Bedfordshire, Cambridgeshire & Peterborough, Essex and Hertfordshire) were selected in 2013 as pathfinder sites to develop new approaches to suicide prevention based in part on the Detroit model.

Since then, Mersey Care, Cambridge and Peterborough Clinical Commissioning Group and Teesside councils have also become aligned with the programme and are continuing with their approach towards improved suicide prevention. The Centre for Mental Health evaluated the work of some of the sites during 2015.

The evaluation found there were a range of activities that had taken suicide prevention activities out into local communities. They included:

• training key public service staff such as GPs, police officers, teachers and housing officers
• training others who may encounter someone at risk of taking their own life, such as pub landlords, coroners, private security staff, faith groups and gym workers
• creating ‘community champions’ to put local people in control of activities relating to promoting positive mental health and signposting to help services
• putting in place practical suicide prevention measures in ‘hot spots’ such as bridges and railways
• working with local newspapers, radio and social media to raise awareness in the wider community
• supporting safety planning for people at risk of suicide, involving families and carers throughout the process
• linking with local crisis services to ensure people get speedy access to evidence-based treatments.

However, subsequent research also highlighted some of the challenges. The marketing of the pilots was seen to be damaging and misleading with regards to creating “zero suicide areas”, rather than suicide prevention areas. It has also been suggested that although the campaigns serve to raise publicity and awareness, there is little evidence that the schemes actually reduce the number of suicides in an area any more than “traditional campaigns” to better signpost people to available support.

In addition, many of the projects struggled past the initial implementation stage to have long-term impact, as the buy-in from local GPs and other service professionals was not as high as was expected.

Final thoughts

Widening and improving access to support and services for people at risk of mental ill health or suicide is a big challenge for health and social care professionals. Identifying those people at risk is one of the key barriers and taking inspiration from schemes like those trialled in Detroit is one way for professionals in the UK to adapt their approaches in order to overcome these barriers.

Providing more opportunities for people to get help, and better training for professionals who may come into contact with people with mental illness are some of the ways that current schemes are trying to address mental health and suicide in particular.

However, as many of the evaluative studies from test sites in the UK have found, going beyond that to take mental health into the community, in order to create whole system pathways of care across multiple settings and professions, remains a challenge.

As the London Assembly report pointed out, another key aspect is creating an open environment for people to talk about how they are feeling. This week is Mental Health Awareness Week 2017 and the theme is ‘surviving to thriving’ – and emphasising that good mental health is more than the absence of a mental health problem. Whether in the workplace or in the home; with friends, family or colleagues; it’s important that everyone feels that they have a space where they can talk, and to cultivate resilience and good mental health.

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