Enhancing the population-wide Northern Ireland Registry of Self-Harm and Suicide Ideation through data linkage

Self-Harm and suicide ideation (i.e. thoughts about dying by suicide) are two of the most important known risk factors for death by suicide. Increasing suicide rates are a major public health concern and Northern Ireland consistently has the highest rate of suicide in the UK and Ireland. Recent policies to reduce the rates of suicide nationwide are now including a focus on reducing self-harm and suicide ideation as these are precursors to suicide. However, little is known about what causes self-harm and suicide ideation, how these two factors are related and what impact they have on mortality risk either individually or in combination. Understanding the individual level, household-level, area-level and health related predictors for self-harm and suicide is of vital public health importance so that intervention services can be targeted accurately. Northern Ireland is unique in that it has a national Registry of Self-Harm that has collated information on all presentations to emergency department for self-harm and suicide ideation since 2012 (approximately 8,000 per/year) and the research team has secured access to these data from the data custodians in each of the Health and Social Care Trusts. The proposed project will link these data to additional health, social services, Census and death data to generate a unique dataset of health and social information to achieve a better understanding of the risk factors associated with self-harm, suicide ideation and death by suicide. Our researchers partners in the Public Health Agency and each of the five Health Trusts have acknowledged that the increased knowledge from this project could be instrumental in shaping future policies around the prevention and treatment of self-harm and suicide ideation.

The overarching aim of the project is to be the first ever population-wide cohort study of both self-harm and suicide ideation, investigating a range of demographic, physical health, mental health and psychosocial factors to tease apart the strength of association between each of these factors and the outcomes of interest to better understand those most at risk. The project will address three overlapping research questions: (i) Which factors are most associated with self-harm/suicide ideation/both, (ii) What happens after self-harm/suicide ideation, and (iii) an evaluation of the 'card before you leave' scheme.

The extensive detail in the Registry of Self-Harm, enhanced by linkage to the Enhanced Prescribing Database (population-wide data on all prescriptions dispensed in community pharmacies in NI), the Social Services Client Administration and Retrieval Environment data (population-wide data on interaction with social services), mortality data from the death register and the 2011 Census data, will be used to explore a range of predictors and outcomes of both self-harm and suicide ideation. Prescription medication data will allow for an investigation into whether or not individuals are using their own medication to self-harm by self-poisoning. Census data will allow for the identification of individuals within households to investigate whether individuals are using medication from other household members. We will capitalise on a naturally occurring experiment within the data to evaluate the 'card before you leave' scheme (a treatment pathway for self-harmers deemed low risk) which was rolled out in 2010 by examining outcomes pre- and post-intervention and identifying those individuals eligible who do and do not avail of the scheme.

This project will be the first to link the Registry of Self-harm to other data sources and will become a pioneer study to facilitate access to this data for other researchers across the UK. The project will also provide a significant training opportunity for ADRC-NI support staff and the associated researchers, including the named early career researcher.

The proposed study will provide a greater understanding of the factors associated with risk and resilience to, and the outcomes of, self-harm and suicide ideation.

The Public Health Agency (PHA) and the five Health Trusts work within the Department of Health in Northern Ireland (NI) to provide prevention services and clinical treatment services. This project will be a partnership between the PHA, the Health Trusts, Queen's University Belfast and the Administrative Data Research Centre-NI (see attached letters of support). Representatives from all partners will sit on a Project Steering Group and will be consulted with regard to the analysis plan, pertinent questions and dissemination of results. Reducing the rate of suicide and self-harm is a key priority in the Government's "Protect Life 2" strategy. The strategy sets out 10 objectives, three of which are directly addressed in the proposed project: Objective 3 - Improve the understanding and identification of suicidal and self-harming behaviour (which is major focus of Strands 1 and 2), Objective 5 - Restrict access to the means of suicide, particularly for people known to be self-harming (which is explored in Strand 1), Objective 10 - Strengthen the local evidence base on suicide patterns, trends and risks, and on effective interventions to prevent suicide and self-harm (explored in Strand 1 and Strand 3 which evaluates an existing intervention).

The Regional Self-Harm Steering Group brings together service providers and commissioners to improve services for people who are at risk of self-harm and ensures the implementation of national guidelines on treatment and prevention. A representative from the Regional Self-Harm Steering Group will sit on the Project Steering group (see attached support letter). This will allow a direct line of communication between researchers disseminating the results of the study and commissioners involved in policy making and implementation.

The results of this study will have a direct impact on organisations who deal on a daily basis with individuals who self-harm or have suicide ideation. The project team is well networked with the Public Initiative for the Prevention of Suicide and Self-Harm (PIPS), a charity that provides support to individuals who have considered or are considering ending their own lives and delivers suicide prevention training and services. Profiling those individuals most at risk and identifying major risk factors for repeat self-harm or suicide risk will give organisations such as this one the tools to identify, highlight and target populations who would benefit most from interventions. A representative from PIPS will sit on the Project Steering Group, will be invited to dissemination activities and all outputs will be shared directly with the PIPS team.

The primary communication for the project will be via a series of small Project Steering Group meetings, a final research seminar and media press releases of findings to correspond with the publication of journal articles supplemented by Twitter communication of all events. The final research seminar (January 2020) will bring together a range of stakeholders, members of the Steering Group and affiliates to present the full range of findings to a mixed academic, policy, practice and public audience. A policy briefing paper will also be presented at the Northern Ireland Assembly's scheduled Research and Information Services Knowledge Exchange Seminar Series 2019.

Methodologically, the PHA, the Health Trusts and the ADRC-NI will benefit from the experience of establishing a new data sharing gateway and this knowledge may be carried forward to future linkage projects using similar data with similar data custodians. Indirectly, individuals such as health care staff, general practitioners and teachers/employers may be able to utilise this research in their day to day activates with a raised awareness of the factors associated with self-harm and suicide ideation.