“ Assisting in improving the care of people who are experiencing mental disorders associated with suicidal behaviours with...
Hawkes Bay DHB mission : <ul><li>Working with others to maximize the health & well being of people in Hawkes Bay and the C...
World Health Organisation… <ul><li>“ One person will die every minute from suicide…” = 60 deaths per hour </li></ul><ul><l...
World Health Organisation… <ul><li>“ More people commit suicide each year than die in all the world’s combined armed confl...
World Health Organisation… <ul><li>“ Approximately one million people committed suicide in 2000” </li></ul><ul><li>“ Ten t...
World Health Organisation… <ul><li>“ Suicide rates have increased by 60% during the last 50 years” </li></ul>
World Health Organisation… <ul><li>A serious global public health problem  </li></ul><ul><li>Prevention and control, unfor...
World Health Organisation… <ul><li>Research indicates that the prevention of suicide, while feasible, involves a whole ser...
“ Attempted suicide” and “Self- Harm” – what’s the difference?  <ul><li>SYNONYMS  </li></ul><ul><ul><li>Self-harm </li></u...
What are the most recent figures for suicide in NZ? = 2006 <ul><li>There were 524 deaths from suicide and 2868 hospitalisa...
What are the most recent figures for suicide in NZ? = 2006 <ul><li>Male suicide rates were almost three times the female s...
What are the most recent figures for suicide in NZ? <ul><li>Māori suicide rates were 10.2 percent lower than in 1998, but ...
What are the most recent figures for suicide in NZ? <ul><li>In 2006, rates of suicide amongst youth (aged 15-24) decreased...
Mental Disorders associated with suicide
Mental Disorders associated with suicide <ul><li>Almost all mental disorders are associated with an increased risk of suic...
Mental Disorders associated with suicide <ul><li>Research evidence has shown that mental disorders are the major contribut...
Hospitalisations for intentional self-harm in NZ 2006 <ul><li>There were 5400 hospitalisations for intentional self-harm i...
Pathways to suicidal behaviour
Common Myths about suicide Myth No. 1 <ul><li>People who talk about suicide will not harm themselves – they just want atte...
Common Myths about suicide Myth No. 2 <ul><li>Suicide is always an impulsive act and happens without warning </li></ul><ul...
Common Myths about suicide Myth No. 3 <ul><li>Suicidal individuals really want to die or are determined to kill themselves...
Common Myths about suicide Myth No. 4 <ul><li>When a person shows signs of improvement, or survives a suicide attempt, the...
Common Myths about suicide Myth No. 5 <ul><li>Suicide is always hereditary </li></ul><ul><li>FALSE </li></ul><ul><li>Famil...
Common Myths about suicide Myth No. 6 <ul><li>You must have a mental illness if you commit suicide </li></ul><ul><li>FALSE...
Common Myths about suicide Myth No. 7 <ul><li>If you talk or ask about suicide, you will make the person more likely to co...
Common Myths about suicide Myth No. 8 <ul><li>Suicide only happens to “those kind of people” </li></ul><ul><li>FALSE </li>...
Common Myths about suicide Myth No. 9 <ul><li>Once a person attempts suicide, they will never do it again </li></ul><ul><l...
Common Myths about suicide Myth No. 10 <ul><li>Children do not commit suicide. </li></ul><ul><li>They do not understand th...
 
Suicide Prevention Strategy
Suicide Prevention Strategy
Suicide Prevention Strategy
Suicide Prevention Strategy
How do you improve care? <ul><li>Supporting the public to recognise and be more responsive to people experiencing symptoms...
How do you improve care? <ul><li>Provide education to the patient and family. </li></ul><ul><li>If a person is (or is like...
How do you improve care? <ul><li>Elicit the presence or absence of suicidal ideation : </li></ul><ul><li>Address the perso...
How do you improve care? <ul><li>Elicit the presence or absence of suicidal ideation : </li></ul><ul><li>Focus on the natu...
How do you improve care? <ul><li>Elicit the presence or absence of suicidal ideation : </li></ul><ul><li>Speak with family...
How do you improve care? <ul><li>Elicit the presence or absence of suicidal ideation : </li></ul><ul><li>If the person is ...
How do you improve care? <ul><li>Elicit the presence or absence of suicidal ideation : </li></ul><ul><li>Probe for detaile...
How do you improve care? <ul><li>Health & Disability Commissioner  </li></ul><ul><li>Case 08HDC08140 : April 2009 </li></u...
Elicit the presence or absence of suicidal ideation. <ul><li>Determine the person’s belief about the lethality of the meth...
Elicit the presence or absence of suicidal ideation. <ul><li>Enquire about the presence of a firearm in the home or workpl...
How do you improve care? <ul><li>“ Grafton Bridge Suicide Study Proves Barriers Effectiveness”  </li></ul><ul><li>Media re...
How do you improve care? <ul><li>“ Where Are They Now? </li></ul><ul><li>A Follow-up Study of Suicide Attempters from the ...
How do you improve care? <ul><li>“ Where Are They Now? </li></ul><ul><li>A Follow-up Study of Suicide Attempters from the ...
How do you improve care? <ul><li>Reduce access to means  </li></ul><ul><li>Example : Domestic gas  </li></ul><ul><li>A swi...
How do you improve care? <ul><li>Stay up to date with research and advances in practice : </li></ul><ul><li>New Zealand Sy...
How do you improve care? <ul><li>Primary Care : G.P.  </li></ul><ul><li>Secondary Care : </li></ul><ul><ul><li>Mental Heal...
How do you improve care? <ul><li>Group exercise : </li></ul><ul><ul><li>Discuss in groups of 3 or 4 what you can achieve l...
Take home messages : <ul><li>People who talk about killing themselves often  do  kill themselves </li></ul><ul><li>Specifi...
Take home messages : <ul><li>Recognise that suicide assessment scales have very low predictive value and do not provide re...
Take home messages : <ul><li>Following an act of self-harm the rate of suicide increases to between 50 and 100 times the r...
Take home messages : <ul><li>Medical illness is associated with increased likelihood of suicide.  </li></ul><ul><li>Almost...
Take home messages : <ul><li>Make it a personal task to commit to reading a key suicide prevention document at least once ...
References :  <ul><li>“ Suicide Prevention Information ” Mental Health Foundation  </li></ul><ul><ul><li>Web page last acc...
References :  <ul><li>“ Preventing suicide at work”  World Health Organisation 2006 </li></ul><ul><ul><li>http://whqlibdoc...
References : <ul><li>&quot;Where are they now? A follow up study of suicide attempters from the Golden Gate Bridge&quot;  ...
References : <ul><li>Suicide Prevention in New Zealand (SPINZ)   </li></ul><ul><ul><li>http://www.spinz.org.nz/page/5-Home...
References : <ul><li>International Association for Suicide Prevention (IASP)  </li></ul><ul><ul><li>Website last accessed ...
<ul><li>Be nice to people </li></ul><ul><li>[email_address] </li></ul><ul><li>June 2009 </li></ul>
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Suicide prevention - New Zealand 2009

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Suicide prevention - New Zealand 2009

  1. 1. “ Assisting in improving the care of people who are experiencing mental disorders associated with suicidal behaviours within the community” This presentation will be emailed upon request, just let me have an email address to send it to. Suicide Prevention
  2. 2. Hawkes Bay DHB mission : <ul><li>Working with others to maximize the health & well being of people in Hawkes Bay and the Chatham Islands </li></ul><ul><li>To be achieved by providing the right care, in the right place, at the right time, by the right people, with the right tools – EVERY TIME </li></ul>
  3. 3. World Health Organisation… <ul><li>“ One person will die every minute from suicide…” = 60 deaths per hour </li></ul><ul><li>“ One person will attempt suicide every three seconds” = 1200 suicide attempts per hour </li></ul>
  4. 4. World Health Organisation… <ul><li>“ More people commit suicide each year than die in all the world’s combined armed conflict’s” </li></ul>
  5. 5. World Health Organisation… <ul><li>“ Approximately one million people committed suicide in 2000” </li></ul><ul><li>“ Ten to twenty times as many people attempted suicide, actual figures are assumed to be higher than this” </li></ul><ul><li>This means that more than 20 million people attempt suicide every year. </li></ul>
  6. 6. World Health Organisation… <ul><li>“ Suicide rates have increased by 60% during the last 50 years” </li></ul>
  7. 7. World Health Organisation… <ul><li>A serious global public health problem </li></ul><ul><li>Prevention and control, unfortunately, are no easy task. </li></ul>
  8. 8. World Health Organisation… <ul><li>Research indicates that the prevention of suicide, while feasible, involves a whole series of activities : </li></ul><ul><ul><li>Provision of the best possible conditions for bringing up our children and youth </li></ul></ul><ul><ul><li>Effective treatment of mental disorders </li></ul></ul><ul><ul><li>Environmental control of risk factors. </li></ul></ul><ul><ul><li>Appropriate dissemination of information and awareness raising are essential elements in the success of suicide prevention </li></ul></ul>
  9. 9. “ Attempted suicide” and “Self- Harm” – what’s the difference? <ul><li>SYNONYMS </li></ul><ul><ul><li>Self-harm </li></ul></ul><ul><ul><li>Deliberate self-harm </li></ul></ul><ul><ul><li>Intentional self-harm </li></ul></ul><ul><ul><li>Parasuicide </li></ul></ul><ul><ul><li>Attempted suicide </li></ul></ul><ul><ul><li>Non-fatal suicidal behaviour </li></ul></ul><ul><ul><li>Self-inflicted violence </li></ul></ul><ul><li>SUB-TYPES </li></ul><ul><ul><li>Self-poisoning </li></ul></ul><ul><ul><li>Self-injury </li></ul></ul><ul><ul><li>Self-mutilation </li></ul></ul>
  10. 10. What are the most recent figures for suicide in NZ? = 2006 <ul><li>There were 524 deaths from suicide and 2868 hospitalisations (where the person was admitted via the emergency department and stayed longer than 48 hours) for intentional self-harm in 2006. </li></ul><ul><li>The suicide rate of 12.2 deaths per 100,000 population declined significantly (by 19.1 percent) since 1998. </li></ul><ul><li>Intentional self-harm hospitalisations have declined significantly (by 18.8 percent) since 1996. </li></ul>
  11. 11. What are the most recent figures for suicide in NZ? = 2006 <ul><li>Male suicide rates were almost three times the female suicide rates in 2006, and female hospitalisations for intentional self-harm are approximately twice those for males. </li></ul><ul><li>Suicide rates for males aged 20-29 decreased by 40 percent since 1996. </li></ul><ul><li>Māori suicide rates (17.2 per 100,000 population) in 2006 were significantly higher than non-Māori suicide rates (11.0 per 100,000 population). </li></ul>
  12. 12. What are the most recent figures for suicide in NZ? <ul><li>Māori suicide rates were 10.2 percent lower than in 1998, but they are variable rather than trending downwards. </li></ul><ul><li>Suicide rates for those in the most deprived socioeconomic quintile (quintile 5) were significantly higher than for those in quintile 1. </li></ul><ul><li>In 2006, males from the most deprived areas were almost three times more likely to be hospitalised than those in the least deprived areas, while females from the most deprived areas were almost twice as likely to be hospitalised as those in the least deprived areas. </li></ul>
  13. 13. What are the most recent figures for suicide in NZ? <ul><li>In 2006, rates of suicide amongst youth (aged 15-24) decreased by 31.5 percent since their peak in 1995. </li></ul><ul><ul><li>Hospitalisations for intentional self-harm amongst youth decreased by 32.5 percent since 1996. </li></ul></ul><ul><li>The male youth (15−24 years) age-specific suicide rate in 2006 was 3.9 times the female rate. </li></ul><ul><ul><li>For self-harm hospitalisations, the opposite was true, with the female youth rate being 2.4 times the male rate. </li></ul></ul>
  14. 14. Mental Disorders associated with suicide
  15. 15. Mental Disorders associated with suicide <ul><li>Almost all mental disorders are associated with an increased risk of suicide </li></ul>
  16. 16. Mental Disorders associated with suicide <ul><li>Research evidence has shown that mental disorders are the major contributor to the development of suicidal behaviour. </li></ul><ul><li>Estimates have suggested that up to 70 percent of suicide attempts can be attributed to mental disorders. </li></ul>
  17. 17. Hospitalisations for intentional self-harm in NZ 2006 <ul><li>There were 5400 hospitalisations for intentional self-harm in 2006, equating to a rate of 151.7 per 100,000 population. </li></ul><ul><ul><li>This represents a 7.5% increase from the rate in 2005 (141.1 per 100,000 or 4,992 hospitalisations). </li></ul></ul><ul><li>The sub-groups of the New Zealand population with the highest intentional self-harm hospitalisation rates in 2006 were females, Maori, those aged 15-24 years, and those residing in the most deprived areas (quintile five). </li></ul>
  18. 18. Pathways to suicidal behaviour
  19. 19. Common Myths about suicide Myth No. 1 <ul><li>People who talk about suicide will not harm themselves – they just want attention </li></ul><ul><li>FALSE </li></ul><ul><li>All threats should be taken seriously </li></ul>
  20. 20. Common Myths about suicide Myth No. 2 <ul><li>Suicide is always an impulsive act and happens without warning </li></ul><ul><li>FALSE </li></ul><ul><li>Suicide is often pondered for some time. </li></ul><ul><li>Many individuals give verbal or behavioural warnings about their intentions </li></ul>
  21. 21. Common Myths about suicide Myth No. 3 <ul><li>Suicidal individuals really want to die or are determined to kill themselves </li></ul><ul><li>FALSE </li></ul><ul><li>Most people who are feeling suicidal will share their thoughts with at least one other person </li></ul>
  22. 22. Common Myths about suicide Myth No. 4 <ul><li>When a person shows signs of improvement, or survives a suicide attempt, they are out of danger </li></ul><ul><li>FALSE </li></ul><ul><li>One of the most dangerous times is immediately following the crisis or when the person is in hospital following an attempt. </li></ul><ul><li>The week following discharge is of particular risk </li></ul>
  23. 23. Common Myths about suicide Myth No. 5 <ul><li>Suicide is always hereditary </li></ul><ul><li>FALSE </li></ul><ul><li>Family history of suicide and depression is important, but not conclusive </li></ul>
  24. 24. Common Myths about suicide Myth No. 6 <ul><li>You must have a mental illness if you commit suicide </li></ul><ul><li>FALSE </li></ul><ul><li>The relative proportion varies, but there are reported suicides where no mental illness was apparent </li></ul>
  25. 25. Common Myths about suicide Myth No. 7 <ul><li>If you talk or ask about suicide, you will make the person more likely to commit suicide </li></ul><ul><li>FALSE </li></ul><ul><li>Validation of the individual’s emotional state and the normalisation of the stress-induced situation are necessary components in reducing suicidal ideation </li></ul>
  26. 26. Common Myths about suicide Myth No. 8 <ul><li>Suicide only happens to “those kind of people” </li></ul><ul><li>FALSE </li></ul><ul><li>Suicide happens to all types of people and is found in all kinds of social systems and families </li></ul>
  27. 27. Common Myths about suicide Myth No. 9 <ul><li>Once a person attempts suicide, they will never do it again </li></ul><ul><li>FALSE </li></ul><ul><li>Previous suicide attempts are a critical predictor of suicide </li></ul><ul><li>1 in 5 will make a further attempt within 1 year </li></ul>
  28. 28. Common Myths about suicide Myth No. 10 <ul><li>Children do not commit suicide. </li></ul><ul><li>They do not understand the finality of death and are cognitively incapable of engaging in a suicidal act </li></ul><ul><li>FALSE </li></ul><ul><li>Although rare, children do commit suicide and ANY gesture at ANY age must be taken seriously </li></ul>
  29. 30. Suicide Prevention Strategy
  30. 31. Suicide Prevention Strategy
  31. 32. Suicide Prevention Strategy
  32. 33. Suicide Prevention Strategy
  33. 34. How do you improve care? <ul><li>Supporting the public to recognise and be more responsive to people experiencing symptoms of mental disorder, including how to seek appropriate help - NZGG </li></ul><ul><li>Improving access to primary and secondary mental health services - NZGG </li></ul>
  34. 35. How do you improve care? <ul><li>Provide education to the patient and family. </li></ul><ul><li>If a person is (or is likely to become) dangerous to him/herself or to others and will not consent to interventions intended to reduce those risks, the worker is justified in attenuating confidentiality to the extent needed to address the safety of the person and / or others. </li></ul><ul><li>Reduce access to any means of suicide </li></ul>
  35. 36. How do you improve care? <ul><li>Elicit the presence or absence of suicidal ideation : </li></ul><ul><li>Address the person’s feelings about living, with questions such as : </li></ul><ul><ul><li>“ How does life seem to you at this point?” </li></ul></ul><ul><ul><li>“ Have you ever felt that life was not worth living?” </li></ul></ul><ul><ul><li>“ Did you ever wish you could go to sleep and just not wake up?” </li></ul></ul>
  36. 37. How do you improve care? <ul><li>Elicit the presence or absence of suicidal ideation : </li></ul><ul><li>Focus on the nature, frequency, extent, and timing of suicidal thoughts, and consider their interpersonal, situational, and symptomatic context. </li></ul>
  37. 38. How do you improve care? <ul><li>Elicit the presence or absence of suicidal ideation : </li></ul><ul><li>Speak with family members or friends to determine whether they have observed behavior (e.g. recent purchase of a gun) or have been privy to thoughts that suggest suicidal ideation. </li></ul>
  38. 39. How do you improve care? <ul><li>Elicit the presence or absence of suicidal ideation : </li></ul><ul><li>If the person is intoxicated with alcohol or other substances when initially interviewed, the person’s suicidality will need to be reassessed at a later time. </li></ul>
  39. 40. How do you improve care? <ul><li>Elicit the presence or absence of suicidal ideation : </li></ul><ul><li>Probe for detailed information about specific plans for suicide and any steps that have been taken toward enacting those plans. </li></ul>
  40. 41. How do you improve care? <ul><li>Health & Disability Commissioner </li></ul><ul><li>Case 08HDC08140 : April 2009 </li></ul><ul><li>“ Where there have been several suicide attempts in a short period, and there is no evidence of long-standing family estrangement, there should be a low threshold for notifying family of the risk of self-harm.” </li></ul>
  41. 42. Elicit the presence or absence of suicidal ideation. <ul><li>Determine the person’s belief about the lethality of the method, which may be as important as the actual lethality of the method. </li></ul><ul><li>Determine the conditions under which the person would consider suicide (e.g., divorce, going to jail, housing loss) and estimate the likelihood that such a plan will be formed or acted on in the near future. </li></ul>
  42. 43. Elicit the presence or absence of suicidal ideation. <ul><li>Enquire about the presence of a firearm in the home or workplace. </li></ul><ul><li>If a firearm is present, discuss with the person or a significant other the importance of restricting access to, securing, or removing this and other weapons. </li></ul>
  43. 44. How do you improve care? <ul><li>“ Grafton Bridge Suicide Study Proves Barriers Effectiveness” </li></ul><ul><li>Media release – Otago University Monday 18 May 2009 </li></ul><ul><li>Safety barriers to prevent suicide by jumping were removed from Grafton Bridge in 1996 after having been in place for 60 years. After they were removed, there was a five-fold increase in the number and rate of suicides from the bridge. These increases led to a decision to reinstall safety barriers. Since the reinstallation of barriers, of an improved design, in 2003, there have been no suicides from the bridge. </li></ul><ul><li>Researchers estimate 14 lives could have been saved if barriers had remained in place. </li></ul>
  44. 45. How do you improve care? <ul><li>“ Where Are They Now? </li></ul><ul><li>A Follow-up Study of Suicide Attempters from the Golden Gate Bridge” </li></ul><ul><li>Richard H. Seiden, Ph.D., M.P.H. University of California at Berkeley 1978 </li></ul><ul><li>Summary and Conclusions </li></ul><ul><ul><li>Subsequent rates of suicide and other violent death are much higher than for the general population. </li></ul></ul><ul><ul><li>Despite the high rates vis-à-vis the general population, still about 90% do not die of suicide or by other violent means. </li></ul></ul>
  45. 46. How do you improve care? <ul><li>“ Where Are They Now? </li></ul><ul><li>A Follow-up Study of Suicide Attempters from the Golden Gate Bridge” </li></ul><ul><li>The major hypothesis under test, that Golden Gate Bridge attempters will surely and inexorably “just go someplace else,” is clearly unsupported by the data. </li></ul><ul><li>Suicidal behavior is crisis-oriented and acute in nature </li></ul><ul><li>Accordingly, the justification for prevention and intervention such as building a suicide prevention barrier is warranted and the prognosis for suicide attempters is, on balance, relatively hopeful. </li></ul>
  46. 47. How do you improve care? <ul><li>Reduce access to means </li></ul><ul><li>Example : Domestic gas </li></ul><ul><li>A switch from toxic to non-toxic domestic gas in UK in the 1970s saw the domestic gas-related suicide rate decline significantly, with a parallel decrease in overall suicide rates (Murphy et al 1986). In Britain and in Switzerland the switch was followed by a reduction in total suicide rates in both countries, with no apparent displacement to other methods. </li></ul>
  47. 48. How do you improve care? <ul><li>Stay up to date with research and advances in practice : </li></ul><ul><li>New Zealand Symposium Sept 10 & 11 2009 </li></ul>
  48. 49. How do you improve care? <ul><li>Primary Care : G.P. </li></ul><ul><li>Secondary Care : </li></ul><ul><ul><li>Mental Health & Addiction Service </li></ul></ul><ul><ul><ul><li>Referral’s received from any person </li></ul></ul></ul><ul><ul><ul><li>Referral Criteria – “People with known or suspected moderate to severe mental health problem” </li></ul></ul></ul><ul><ul><ul><li>Crisis Assessment & Treatment Team </li></ul></ul></ul><ul><ul><ul><ul><li>0800 112 334 </li></ul></ul></ul></ul>
  49. 50. How do you improve care? <ul><li>Group exercise : </li></ul><ul><ul><li>Discuss in groups of 3 or 4 what you can achieve locally to assist in the care of people who are experiencing mental disorders associated with suicidal behaviours within the community </li></ul></ul><ul><ul><li>One person from each group to feedback to all participants </li></ul></ul>
  50. 51. Take home messages : <ul><li>People who talk about killing themselves often do kill themselves </li></ul><ul><li>Specifically inquire about suicidal thoughts, plans, and behaviours </li></ul>
  51. 52. Take home messages : <ul><li>Recognise that suicide assessment scales have very low predictive value and do not provide reliable estimates of suicide risk </li></ul><ul><li>Identify factors that may increase or decrease the person’s level of risk. </li></ul>
  52. 53. Take home messages : <ul><li>Following an act of self-harm the rate of suicide increases to between 50 and 100 times the rate of suicide in the general population </li></ul><ul><li>The presence of a psychiatric disorder is the most significant risk factor for suicide. </li></ul>
  53. 54. Take home messages : <ul><li>Medical illness is associated with increased likelihood of suicide. </li></ul><ul><li>Almost all psychiatric disorders have been shown to increase suicide risk. </li></ul>
  54. 55. Take home messages : <ul><li>Make it a personal task to commit to reading a key suicide prevention document at least once every year. </li></ul><ul><li>Perhaps do that on every World Suicide Prevention Day, September 10th…? </li></ul>
  55. 56. References : <ul><li>“ Suicide Prevention Information ” Mental Health Foundation </li></ul><ul><ul><li>Web page last accessed 09.06.09 http://www.mentalhealth.org.nz/shop/listing/view/3/ </li></ul></ul><ul><li>“ Suicide Facts: Deaths and Intentional Self-harm Hospitalisations 2006 ” </li></ul><ul><ul><li>Published in 2008 by the Ministry of Health : http://www.moh.govt.nz/moh.nsf/pagesmh/8697/$File/suicide-deaths-int-selfharm-2006+V7pp.pdf </li></ul></ul><ul><li>“ Preventing suicide A resource for counsellors” World Health Organisation 2006 </li></ul><ul><ul><li>http://whqlibdoc.who.int/publications/2006/9241594314_eng.pdf </li></ul></ul>
  56. 57. References : <ul><li>“ Preventing suicide at work” World Health Organisation 2006 </li></ul><ul><ul><li>http://whqlibdoc.who.int/publications/2006/9241594381_eng.pdf </li></ul></ul><ul><li>“ Assessment and Treatment of Patients With Suicidal Behaviors ” </li></ul><ul><ul><li>American Psychiatric Association 2003 http://www.psychiatryonline.com/pracGuide/pracGuideTopic_14.aspx </li></ul></ul>
  57. 58. References : <ul><li>&quot;Where are they now? A follow up study of suicide attempters from the Golden Gate Bridge&quot; </li></ul><ul><ul><li>Richard Seiden UCB 1978 http://www.pfnc.org/PFNC-GGBSeidenArticle4.pdf </li></ul></ul><ul><li>“ Self-harm : The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care” </li></ul><ul><ul><li>UK National Clinical Practice Guideline Number 16 : National Collaborating Centre for Mental Health National Institute for Clinical Excellence 2004 http://www.nice.org.uk/nicemedia/pdf/CG16FullGuideline.pdf </li></ul></ul>
  58. 59. References : <ul><li>Suicide Prevention in New Zealand (SPINZ) </li></ul><ul><ul><li>http://www.spinz.org.nz/page/5-Home </li></ul></ul><ul><ul><ul><li>Suicide Prevention in New Zealand (SPINZ) Info sheet No 1 </li></ul></ul></ul><ul><ul><ul><ul><li>http://dnload.net/?http://www.spinz.org.nz/file/dnload/downloads/pdf/file_144.pdf </li></ul></ul></ul></ul><ul><ul><ul><li>Suicide Prevention in New Zealand (SPINZ) Info sheet No 2 </li></ul></ul></ul><ul><ul><ul><ul><li>http://dnload.net/?http://www.spinz.org.nz/file/dnload/downloads/pdf/file_145.pdf </li></ul></ul></ul></ul>
  59. 60. References : <ul><li>International Association for Suicide Prevention (IASP) </li></ul><ul><ul><li>Website last accessed 15.06.09 </li></ul></ul><ul><ul><li>International Association for Suicide Prevention - Home - IASP </li></ul></ul>
  60. 61. <ul><li>Be nice to people </li></ul><ul><li>[email_address] </li></ul><ul><li>June 2009 </li></ul>
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