Norfolk Suicide Audit 2024

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Key findings

• Suicides in Norfolk are largely consistent with national data regarding rates, cohorts and personal risk factors.

• After a large increase in the early 2010s, suicide rates in Norfolk have reduced in the mid- to late 2010’s. In the 2021-2023 time period they were similar to the average values for England, where rates have increased in the last five to seven years.

• Unlike similar counties, Norfolk has not seen a rise in suicide rates in the last eight years.

• Norwich has consistently had the highest or second highest suicide rates among the Norfolk lower tier local authority areas.

• Around three in four individuals who die by suicide are men.

• The risk of suicide is highest in men in their 40s and over the age of 80.

• Living in a relatively more deprived area is a key risk factor, as is living alone.

• There was also some evidence that suicide rates in Norfolk were higher among those born in European Union (EU) countries.

• Most suicides occur at home and by hanging.

• Risk factors for suicide are diverse and often act in combination. Eighty percent of the individuals whose inquest files were reviewed had one or several diagnosed mental health conditions, most commonly depression or anxiety.

• The most common predictor of suicides is previous self-harm including suicide attempts. For a minority of suicides, there had been prior attempts that were not known to support services.

• Common issues experienced by those taking their own lives in Norfolk:

  • Poor physical health

  • Economic difficulties such as unemployment or employment in routine or semi-routine occupations

  • Living alone and/or feeling lonely

  • Substance misuse

  • Adverse experiences such as domestic abuse in childhood or by an intimate partner

  • Relationship breakdown

  • Contact with the Criminal Justice System

• The national suicide prevention strategy further highlights neurodiversity and autism, pregnancy and maternity, gambling problems, and bereavement by suicide as important risk factors.

• The majority of people had a primary care contact in the last year of their life, but many did not discuss mental health issues with their GP.

• Around half had been seen in a hospital in the year before their death, and fewer than half had been in contact with mental health services in the year before their death.

• Many of those who died by suicide had been prescribed one or more psychoactive substances, most commonly antidepressants.

• People with a diagnosed severe mental illness had the most contacts with primary care as well as mental health services, more commonly had a psychiatric inpatient history, and had more psychoactive substances prescribed than those with any other or no mental health diagnosis.

• Some people who died by suicide had recent contact with mental health services. A considerable proportion of people had no previous contact.

• Financial hardship was a direct impact of Covid-19 for some, and for many has been compounded by the cost of living crisis. For around one in eight suicides that took place since the start of the pandemic, Covid-19 was specifically mentioned as part of risk factors around isolation and anxiety, and limiting access to services. There is no evidence that suicides have increased during the pandemic.

1 Introduction and definition

Suicide is a leading cause of years of life lost and has devastating impacts on families and communities. On average, around 135 people are exposed to each individual suicide (Cerel, et al., 2019)¹, with strong effects on those close to the deceased (Pitman, Osborn, King, & Erlangsen, 2014)². Complex histories of risk factors and distressing events lead to suicide, but significant social and gender inequalities in suicide risk persist. In September 2023, the Sunak Conservative government published it’s 5-year suicide prevention strategy for England. This local suicide audit has been undertaken to inform the suicide prevention plan for Norfolk which aims to reduce the number of suicides and tackle those inequalities.

The Office for National Statistics (ONS) defines suicide as “death from intentional self-harm in individuals aged 10 years and over”, or “death by injury of undetermined intent in people aged 15 years and over” (ONS, 2023)³. The former group includes deaths where a coroner has given a suicide conclusion or made it clear in the narrative conclusion that the deceased intended to take their own life (ICD10 codes X60-X84). The latter group includes deaths for which the coroner has given an open conclusion (ICD10 codes Y10-Y34). Official statistics by the ONS are based on the year in which a death was registered rather than on when the death occurred.

The standard of proof used by coroners to determine suicides was changed in 2018 from a criminal (beyond reasonable doubt) to a civil standard (more likely than not). There is no evidence that this has changed reported suicide rates (Office for National Statistics, 2020)⁴. Research pre-dating the change showed that the likelihood of a suicide conclusion varies between coroners in England, and deaths with certain characteristics, for example deaths by poisoning, were less likely to receive a suicide conclusion⁵. A study in Israel came to similar conclusions about the relationship between types of deaths and suicide conclusions⁶. To our knowledge, it is unknown how the relationship between death circumstances and coroner conclusions has changed following the adjustment to the standard of proof in the UK. However, official suicide statistics in the UK have long been including deaths of undetermined intent, so there are arguably fewer ‘hidden’ suicides in the UK than in other countries with different coding practices⁷.

2 Audit Methods

This document is an audit of 961 suicides in Norfolk registered in 2014 to 2023. The data was accessed through the Civil Registrations of Death (CRD) database. 904 of these were suicides by people with a registered address in Norfolk. Following official suicide statistics, numbers here are based on the year of registration rather than year of death. As it currently stands, there is a time delay from death to registration which has grown as a consequence of disruptions to the coronial process caused by the Covid-19 pandemic. The median registration delay for Norfolk has been similar to the England average in recent years. Nevertheless, it is important to bear in mind the impact such time delays have on official suicide statistics. Depending on whether the delay increases further or decreases in the future, changes in delays will contribute to potential changes in suicide rates reported for Norfolk.

The audit further included an in-depth review of coroner’s inquest files (Coroner Inquest Files) for 202 suicides that occurred between 2019 and 2023. Inquests are carried out by the coroner’s office and are a comprehensive investigation of deaths that are suspected suicides as identified by the coroner’s office (https://www.cps.gov.uk/legal-guidance/coroners). Because coronial jurisdiction follows county rather than Integrated Care System boundaries, data for the Waveney area is not included in this audit but is instead included in the suicide audit for Suffolk. Data was entered by two different Public Health analysts into a spreadsheet-based database which was comprised of a mixture of quantitative as well as qualitative (free-text) fields.

To identify risk factors in Norfolk, information was obtained on widely available key characteristics based on residential location as well as occupation. This was then combined with more detailed information available for a subset of suicides included in Coroner Inquest Files. Witness statements by relatives, friends, colleagues and first responders gave insight into the lives as well as the circumstances surrounding the death of people who died by suicide. The files also included reports from primary care and mental health services that detailed their interactions with the individuals who took their own lives. In some circumstances little information was available, such that some risk factors are based on limited information.

Some individual characteristics which are known to be associated with suicide risk are not systematically and/or reliably collected in the context of an inquest. Among those are ethnicity, gender identity, sexual orientation, and (undiagnosed) neurodiversity. There are important caveats associated with relying on Coroner Inquest Files, with national research suggesting a focus on explanations made after the event⁸, and on medical explanations with less attention given to social aspects⁹. Information recorded in Coroner Inquest Files may also highlight a subset of known risk factors. We selected a pre-defined list of 33 potential individual risk factors based on the suicide literature and previous suicide audits. We later grouped individual risk factors for further analyses. We assessed the presence or absence of these risk factors based on all available documentation. Further, we used a free-text field for recording any additional relevant risk factors, such as effects of the Covid-19 pandemic. Where a particular risk factor was not mentioned we assumed it was unlikely to have been present. This may have led to underestimations regarding the prevalence of some risk factors among suicides in Norfolk. Nevertheless, locally, the Coroner Inquest Files represent the best available source of information and a valuable opportunity for identifying factors thought to have contributed to individuals taking their own life.

Throughout this audit, where numbers or crude rates are shown, small numbers (1-7) have been suppressed (indicated by *) and all other numbers have been rounded to the nearest five when they are based on the Civil Registrations of Death database, in accordance with NHS Digital statistical disclosure control rules. Numbers based on Coroner Inquest Files are suppressed if they are smaller than five (1-4) and there was a statistical disclosure risk. Unless otherwise specified, error bars in figures represent 95% confidence intervals.

3 General overview

3.1 Suicide rates in Norfolk

The suicide rate in Norfolk was significantly higher than national and regional rates from 2013-2016. More recently, it has not been significantly higher than the suicide rate in England, for which there has been an increasing trend over the last 15 years. The Norfolk suicide rate was higher than the East of England regional average in the most recent period 2021-2023 (Figure 1), though not statistically significantly so.

Local and national suicide rates

Figure 1: Suicide rates per 100,000 residents in Norfolk, East of England, and England from 2001-2023. Three-year periods, based on date of registration. The 95% confidence interval is shown for Norfolk in green shading.

Compared to CIPFA (Chartered Institute of Public Finance and Accountancy) statistical ‘nearest’ neighbours, other local authorities with demographic and economic characteristics similar to Norfolk, the suicide rate in the most recent time period in Norfolk was lower than in eight of the twelve most similar counties. Lancashire, Lincolnshire and Worcestershire had the highest rates. Unlike most of its statistical neighbours, Norfolk has not seen a rise in suicide rates in the last five years (Figure 2).

Suicide rates in Norfolk and similar counties

Figure 2: Suicide rates per 100,000 residents in Norfolk (green), compared to similar counties (CIPFA ‘nearest’ neighbours), from 2001-2023. Three-year periods, based on date of registration. The 95% confidence interval is shown for Norfolk in green shading.

3.2 Male suicides

More men than women take their own lives in most countries including the UK¹⁰. In Norfolk, around three in four individuals who die by suicide are male. The highest suicide rates are seen in middle-aged and very old men (Figure 3 & Table 1). Women in their 40s and 50s have the highest suicide rate for their sex.

Age- and sex-specific suicide rates in Norfolk

Figure 3: Age-specific suicide rates for males and females in Norfolk, for suicides registered between 2014 and 2023 (N = 904). Rates based on small numbers are suppressed, indicated by an asterisk.

Table 1: Suicides and suicide rates (deaths per 100,000 residents) in Norfolk registered 2014-2023 by sex by 5-year age group. Source: Civil Registrations Database (N = 961).

Age group	Male Suicides 2014-2023	Male Suicide rate	Female Suicides 2014-2023	Female Suicide rate
10-14	0	0 [0-1.6]	*	*
15-19	20	8.3 [5.4-12.8]	10	4.3 [2.4-8]
20-24	35	13.2 [9.5-18.3]	10	3.9 [2.1-7.1]
25-29	60	22.7 [17.7-29.3]	*	*
30-34	55	21.3 [16.4-27.7]	10	3.9 [2.1-7.1]
35-39	55	22.3 [17.1-29]	15	6 [3.6-9.9]
40-44	60	24.5 [19.1-31.6]	10	4 [2.2-7.4]
45-49	75	26.4 [21-33]	25	8.5 [5.8-12.6]
50-54	70	22.8 [18-28.8]	30	9.5 [6.6-13.5]
55-59	70	23.5 [18.6-29.7]	20	6.4 [4.2-9.9]
60-64	45	16.4 [12.3-21.9]	20	6.8 [4.4-10.4]
65-69	40	14.1 [10.3-19.2]	10	3.3 [1.8-6]
70-74	40	14.4 [10.6-19.6]	15	5.1 [3.1-8.4]
75-79	15	7.5 [4.6-12.4]	10	4.6 [2.5-8.5]
80-84	30	21.7 [15.2-30.9]	*	*
85-89	25	32.1 [21.7-47.4]	*	*
90+	15	42.5 [25.7-70.1]	*	*

3.3 Age group trends

There have not been any significant changes in the suicide rates in Norfolk by age category in 2019-2023 compared to 2014-2018 (Figure 4). There has been a very minor increase in those aged under 25, and minor decreases in suicide rates in the three broad age groups over 35. Nevertheless, suicide rates are still the highest for individuals aged 35-64.

Change in age-specific suicide rates in Norfolk

Figure 4: Change in crude suicide rates by broad age categories in the last five years compared to the five years prior.

3.4 Norfolk lower tier local authority areas

It is worth noting that there is statistical uncertainty in suicide rates at the geographical level of local authority areas (large confidence intervals in Figure 5). Since the early 2000s, Norwich has consistently had one of the highest suicide rates of residents among Norfolk lower tier local authorities. The suicide rates of other lower tier local authority areas vary substantially between time periods. However, North Norfolk has seen a sustained rise from 2010 to 2021, starting from a very low rate in 2010. In the most recent period with available data (2021-2023), Norwich and Great Yarmouth tended to have a higher suicide rate than other areas of Norfolk (Figure 5).

Lower Tier Local Authority suicide rates

Figure 5: Suicide rates for Norfolk and its lower tier local authority areas, for suicides registered 2021-2023.

3.5 Method and location of suicides

Hanging/suffocation was by far the most common suicide method overall, accounting for more than half (56%) of all suicides in Norfolk, as has been the case nationally in the last 20 years. Poisoning (20%), predominantly through medication overdoses, and drowning (6%) were the next most common methods. Although hanging/suffocation and poisoning were the most common methods in both sexes, there were some differences between men and women in the relative prevalence of suicide methods (Table 2).

Table 2: Method of suicides in Norfolk registered 2014-2023 by sex. Source: Civil Registrations Database (N = 961). Asterisks indicate small numbers suppressed due to confidentiality.

Method	Male	Female	Total
Hanging/Suffocation	60%	43%	56%
Poisoning	17%	33%	20%
Drowning	5%	10%	6%
Cutting/Stabbing	5%	*	4%
Other	4%	*	4%
Shooting	5%	*	4%
Train collision	3%	*	3%
Burning	1%	*	2%
Jumping from height	*	*	1%
Not known	*	0%	*
Road vehicle collision	*	0%	*

Most notably, a third of women who took their own lives did so by poisoning, compared with fewer than one fifth of men (Figure 6). Drowning was also relatively more common in women (10%) than in men (5%). However, compared to hanging/suffocation and poisoning, drowning remains a relatively rare suicide method.

Suicide methods in Norfolk

Figure 6: Method of suicide in men and women in Norfolk for deaths registered between 2014 and 2024 (N = 961). Methods with fewer than 8 suicides in one or both sexes are pooled.

For almost half of all individuals who died by poisoning, and for whom there was detailed information available through Coroner Inquest Files, the cause of death involved medication prescribed to them (Figure 7). Over-the-counter drugs or industrial products were the cause of death in one third of poisoning deaths. Illicit drugs were the cause of death in fewer than 10% of poisoning deaths. Of the files reviewed, there was a very small number of incidents where the individual had used medication prescribed to someone else to take their own life.

Poisoning suicides in Norfolk

Figure 7: Origins of substances involved in poisoning suicides in Norfolk.

Suicide by self-poisoning was not associated with being known to drug and alcohol services. For most individuals (90%) who died by self-poisoning suicide there was no known contact with the substance misuse service Change Grow Live (CGL). And out of 18 individuals who were known to CGL, only five died by self-poisoning suicide.

There was an association between being known to CGL and toxicology indicating drug and alcohol use near the time of death. Fourteen out of 18 (78%) of the individuals known to CGL had alcohol and/or non-prescribed drugs present in their body at the time of death, compared to 38% of people who were not known to CGL.

Three in five (59%) suicides in Norfolk occurred at home (Figure 8 & Table 3). The remaining suicides took place in locations such as woodlands and other outside areas (12%), institutions and residential homes (6%; e.g., prisons), roads (5%), bodies of water (4%), commercial buildings (3%; e.g., car parks), railway lines or stations (3%) and hotels (2%). For 7% of suicides the location was unknown, most likely because the person died in hospital after attempting suicide elsewhere. Suicide location was more often unknown for women, likely because poisoning is more common for women, and individuals who die by poisoning are more likely to die in hospital than those dying from other suicide methods.

Suicide locations in Norfolk

Figure 8: Location of suicide (N = 961). Location types with fewer than 8 suicides in one or both sexes are pooled.

Table 3: Location of suicides in Norfolk registered 2012-2021 by sex. Source: Civil Registrations Database (N = 961).

Location	Male	Female	Total
Private residence	57%	62%	59%
Woodland and other outside areas	13%	7%	12%
Unknown	6%	12%	7%
Institution/Residential home	6%	5%	6%
Road	5%	*	5%
River/lake	3%	5%	4%
Industrial/Commercial	3%	*	3%
Railway line/station	3%	*	3%
Hotel	2%	*	2%
Other public inside area	*	0%	*

4 Suicide risk factors

While there are often many different and complex circumstances that lead to someone taking their own life, studies of suicides across large populations have shown that a range of characteristics are associated with elevated suicide risk¹¹. More broadly, there are certain characteristics measured at a population level that are associated with rates of suicides as well as drug and alcohol related deaths, giving insight into risk factors. Such associations between factors such as living alone, unemployment and elementary occupations with deaths of despair — suicides and drug and alcohol related deaths — have been identified in a recent study.

Therefore, although all individuals’ circumstances are unique, identifying common risk factors can aid the development of targeted intervention measures. Outlined below are identified risk factors for Norfolk residents based on the data analysed for this suicide audit, as well as risk factors identified as priorities in national and local suicide prevention strategies.

Negative life events can have a strong impact on wellbeing and suicidal thoughts and actions. An alternative approach to considering risk factors is thinking about the absence of protective factors for wellbeing. Suicide may often arise from an absence of protective factors such as good quality relationships and support networks, access to work and meaningful employment, secure and comfortable housing, and good physical health or effective pain management.

4.1 Risk factors within communities: deprivation and poor social cohesion

Wider determinants of health are a diverse range of social, economic and environmental factors which impact on people’s health and wellbeing. Suicide risk can be shaped by these wider determinants¹².

Deprivation

The suicide rate continues to be higher among individuals living in more deprived areas of Norfolk, with clear evidence of a decreased rate in less deprived areas (Figure 9). The relationship between deprivation and numerous public health outcomes is well-established at international, national, and local levels. National research shows that mental health conditions such as depression and severe mental illness are more prevalent in relatively more deprived areas.

Deprivation is measured through the Index of Multiple Deprivation (IMD), which combines information on income, employment, education, health, crime, housing & services, and the living environment¹³. Overall, Norfolk ranks 84th most deprived among 151 local authorities in England. The county is relatively more deprived in the Education, Skills and Training domain of the IMD and relatively less deprived with respect to crime. The most deprived areas of Norfolk are found in the urban centres of Norwich, Great Yarmouth, and King’s Lynn, as well as in some rural and coastal areas of the county (Norfolk County Council, 2023)¹⁴. Many of these areas are Core20 areas, the most deprived 20% of areas nationally, which are a priority focus of the local Integrated Care Board’s (ICB) approach to reducing health inequalities. Improving healthcare access for those with severe mental illness is another priority of the ICB’s approach.

Suicide rates by deprivation

Figure 9: Suicide rates in Norfolk by deprivation of residential area (N = 904).

Country of birth

Information on nationality or ethnicity is not available in the CRD, so country of birth was used here instead. There is an indication of higher rates of suicide among individuals born in EU countries compared to those born in the UK or elsewhere (Figure 10). A large proportion of EU-born Norfolk residents live in the most deprived areas of Norfolk.

Suicide rates by country of birth

Figure 10: Suicide rates in Norfolk by country of birth (N = 904). The population in Norfolk born in the UK and elsewhere is estimated from the ONS Annual Population Survey.

A national study that explicitly used ethnicity data through linked records found that a very limited number of ethnic minority groups, namely people who identified as being from a Mixed heritage background or White Gypsy or Irish Travellers, had suicide rates that were statistically higher than the White British majority. That study reported suicide rates for males and females identifying as being an Other white ethnicity lower than individuals of White British ethnicity. It also found that migrants had a lower suicide rate than non-migrants. One reason for the discrepancy with the result based on country of birth reported here could be that the denominator population for country of birth used was not split by sex or age groups. If more men than women born in EU countries live in Norfolk, and/or most people born in EU countries living in Norfolk are middle-aged, then the higher suicide rate might be explained by the higher suicide rates for men and middle-aged people alone.

Among the Coroner Inquest files reviewed for this audit, there were no suicides where Gypsy, Roma or Traveler ethnicity was indicated. However, ethnicity is not systematically recorded as part of the coronial process.

Living alone

The social environment is known to have important effects on suicide risk¹⁵. Supportive social interactions can act as protective factors against suicide, while social tensions and conflict can increase risk. Living alone is one known risk factor for suicides as well as for alcohol and drug related deaths¹⁶. Of the individuals whose Coroner Inquest Files were reviewed, more than one in three (36%) lived alone, while just over half (52%) lived with their partner, their ex-partner or their family; 10% either lived in institutions (prisons, hospitals, care homes) or in temporary or shared accommodation, and for fewer than five the living situation was unknown. While comparing this distribution to the general Norfolk population is difficult due to a lack of available data, estimates for the East of England indicate around one in ten individuals live alone, a considerably lower proportion than the one in three individuals who took their own lives among the Coroner Inquest Files reviewed. National research shows that patients in contact with mental health services who live alone are at especially high risk, as they are more often discharged from institutions without social support. Other risk factors such as relationship breakdown or bereavement may also co-occur with living alone.

Unemployment

Unemployment is a well-documented socio-economic risk factor for suicide¹⁷. Among the 123 individuals of working age (16-64 years old) with available information in their inquest file, more individuals who died by suicide (green circles; Figure 11) were unemployed, compared to the level of unemployment in the general population (blue symbols). Employed individuals were under-represented among suicides compared to the general population (Figure 11). The representation of economically inactive individuals (retired or detained, students, those on disability benefits or long-term sick-leave) was broadly in line with their representation in the general population.

Unemployment and suicides

Figure 11: Distribution of employment status of working age population in Norfolk for suicides and in the general population. Error bars show the range of estimates in the last ten years.

Occupation

An analysis of suicides in different occupational groups from 2011 to 2015 was published by the ONS in 2017. It showed that suicide risk largely followed income levels, with suicide rates being highest in the lowest-skilled and lowest-paid occupations. More recent suicide rates by occupation have not been published, but the ONS states that “occupational differences in suicide risk on the whole have been consistent across time.”

In Norfolk, there is a gradient with the highest suicide rates among men whose socio-economic class is categorised by routine or semi-routine occupations (Figure 12). The picture is less clear among women, where suicide rates in routine and managerial occupations are similar. Numbers of suicides are also much smaller for women, so any potential trends will be less obvious. Data available through Norfolk Insight shows that generally, more Norfolk residents work in occupations associated with lower educational attainment and less workplace autonomy compared to the East of England region and England.

For 29% of individuals aged 16-64, there was no information on occupation available through the deaths database. This was similar for death registrations used by the ONS, where occupation was unavailable for around a third of suicides.

Suicide rates by occupation

Figure 12: Suicide rates by socio-economic class of the workforce aged 16-64 in Norfolk (N = 523). Circle sizes indicate the relative size of the workforce among the socio-economic classes as per the 2021 census.

4.2 Individual risk factors

In this audit, risk factors are grouped loosely in respect of community and individual risk factors, and for the purposes of this analysis they are based on social factors or individual circumstances. We acknowledge that these may be interpreted subjectively. Here, we refer to individual risk factors as those that may have had an immediate and direct effect on suicide and were mentioned by witnesses, family members or those employed in services in contact with those who died by suicide.

Risk factors highlighted in national suicide prevention policy

The national suicide prevention strategy emphasises the role of social determinants of health such as housing, poverty, employment and education on suicide risk. Addressing these risk factors is likely to contribute to preventing suicides at a population level. We have addressed some of these as part of the community risk factors in the previous section.

The national strategy also specifically highlights the following individual risk factors:

• physical illness (mentioned in 48% of Norfolk coroner inquest files) - as shown in Figure 15, this risk factor is present mainly in older and middle-aged individuals. Three in four individuals aged 60+ had poor physical health as a potentially contributing risk factor. NICE guidance highlights that about 20% of patients with a chronic physical health problem suffer from depression, a prevalence approximately two to three times higher than among people who have good physical health.

• financial difficulty and economic adversity (mentioned in 37% of Norfolk coroner inquest files; financial and/or employment problems) - combining inquest file reviews with those undertaken as part of the 2022 suicide audit reveals an increasing trend in the prevalence of material problems from around 10% in 2017 to around 30% from 2018 to 2022 and almost 50% in 2023. The full effects of the cost of living crisis cannot yet be assessed, but there is valid concern that economic hardship will have a measurable impact on suicide rates similar to effects of the 2008-2010 financial recession.

• substance misuse (history of drug and/or alcohol misuse mentioned in 37% of Norfolk coroner inquest files) - 15% had a problem only with alcohol, 6% with drugs only, and 16% with both. Mental health and substance misuse co-morbidities are common among those who die by suicide. National research shows other risk factors such as economic adversity and interpersonal problems are prevalent in people in contact with substance misuse services. An additional potential impact of substance misuse on suicide risk which is not captured here is its short-term effect on impulsiveness.

• domestic abuse (mentioned in 22% of Norfolk coroner inquest files; alleged victims and/or perpetrators) - Domestic abuse, either from family members or intimate partners can severely impact on mental health and suicide risk. The prevalence among Norfolk suicides was not as high as among suspected suicides in research from the Kent & Medway geography.

• social isolation and loneliness (mention of loneliness in 20% of Norfolk coroner inquest files) - this risk factor was most pronounced among older people, although the prevalence was much lower than poor physical health.

• harmful gambling (mentioned in 3% of Norfolk coroner inquest files) - it is unclear whether this low prevalence as a risk factor among suicides in Norfolk indicates harmful gambling is less of a problem than elsewhere, or if harmful gambling is often not identified as a risk factor as part of the inquest process.

The national suicide prevention strategy also highlights the following priority cohorts for prevention efforts:

• Children and young people (no increasing trend in last decade in Norfolk) - although suicide rates for young age groups are lower than for middle-aged and older adults, nationally there has been an upward trend in young people aged 10-24 since 2012, particularly in females. There has not been a significant rise in suicide rates in Norfolk in 2019-2023, compared to 2014-2018, as shown earlier (Figure 4).

Experiences in childhood are undoubtedly important for shaping suicide risk later in young people and adults alike. Adverse childhood experiences were mentioned in 13% of Norfolk coroner inquest files. The real prevalence of adverse childhood experiences among suicides is likely to be higher in reality, as evidence for risk factors will probably focus on recent events and risk factors. A national survey shows that adverse childhood experiences influence health and health-seeking behaviour in later life. This highlights the importance of early promotion of good mental health in children, for example through CYP mental health teams.

• Middle-aged men (consistently high suicide rates in Norfolk) - national research highlighted risk factors such as economic adversity, physical health, substance misuse and self-harm, and showed that, contrary to widely-held beliefs, middle-aged men do seek help.

• People who have self-harmed (self-harm and/or suicide attempt mentioned in 54% of Norfolk coroner inquest files) - a report on mental health patients (contact with mental health services in the year before death) dying by suicide in the UK between 2011 and 2021 showed the incidence of self-harm was 63%.

• People in contact with mental health services (some mental health service contact mentioned in 52% of Norfolk coroner inquest files) - the same report as above shows that co-morbidity, self-harm and alcohol and drug misuse are high among mental health service patients who die by suicide.

• People in contact with the criminal justice system (criminal justice contact as alleged perpetrator of crime or previous prison sentence in 20% of Norfolk coroner inquest files) - most often this related to drink driving offences, assault, domestic abuse or sexual offences. The prevalence was much higher among men (24%) than among women (8%). In some cases, being investigated for a potential crime caused distress which was thought to have contributed to a suicide.

• Autistic people (neurodiversity and/or autism mentioned in 5% of Norfolk coroner inquest files) - studies show that premature mortality is higher for autistic people for a number of reasons, including suicide¹⁸, and that autistic traits are overrepresented among people who die by suicide, compared to the general population¹⁹. Autism may often not be formally diagnosed. A pilot study is developing a suicide prevention tool aimed at mitigating the risk of self-harm and suicidal behaviour in autistic adults. NHS England has published guidance on how to better meet the mental health needs of autistic adults.

• Pregnant women and new mothers (interpreted as having had a potential impact in 4% of Norfolk coroner inquest files on female suicides) - the national strategy highlights that while the prevalence of this risk factor among all suicides is low, suicide risk is high when compared against other causes of death for pregnant women and new mothers.

• People bereaved by suicide (explicitly mentioned in 6% of Norfolk coroner inquest files) - a review found evidence for increased suicide risk after bereavement by suicide, especially in partners and mothers of adults who died by suicide²⁰. Bereavement more broadly is a known risk factor for suicide²¹, and was recorded as a potential contributory factor in 27% of Norfolk coroner inquest files.

Risk factors highlighted in Norfolk and Waveney’s suicide prevention strategy

The Norfolk and Waveney Integrated Care Board’s Suicide Prevention Strategy refresh for 2024-2028 has been developed considering the national strategy alongside local intelligence. The local strategy aligns with the national strategy while paying particular attention to where local evidence is strongest, informed by previous Norfolk suicide audits, Norfolk’s Real-Time Suspected Suicide Surveillance system, and a pilot project for Accident and Emergency attendances relating to self-harm.

The identified priority cohorts mostly align with priority groups from the national strategy, which are listed below. For some cohorts, local intelligence supports a particular focus based on local real-time surveillance of suspected suicides and on the 2022 Norfolk suicide audit:

• Children and Young People who self-harm

• People who have made known previous suicide attempts

• People who have had wellbeing contact with primary and secondary care services.

• Autistic people

• People who are lonely

• Men who have experienced relationship breakdown

• Men from diverse backgrounds

• Older men with long-term limiting physical health conditions

To better support these cohorts, the proposed partnership priorities are improving residents’ awareness of local support and improving community connectedness, creating clear pathways for primary care staff to support people with diagnosed mental health conditions through wellbeing initiatives alongside medication, raising awareness of pathways into primary care and community support among frontline workers, and reducing the number of unexpected deaths of people under the care of the local mental health trust.

Risk factors for men and women

The contribution of broad risk factors was similar for suicides in men and women. Exceptions were addiction and crime, which were more common among males than among females who died by suicide (Figure 13). Note that many suicides had multiple risk factors present.

Suicide risk factors by sex

Figure 13: Prevalence of risk factor groups in men and women who died by suicide in Norfolk, recorded in Coroner Inquest Files.

Relationships

Relationship breakdown is known to be a strong risk factor for suicide. A study by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) showed a high incidence of men not in relationship and/or living alone among suicides. There is some evidence that separation is a stronger risk factor than divorce, and that men are at a higher risk than women following relationship breakdown^{22 23}. In the Norfolk Coroner Inquest Files reviewed, the proportion of males and females who were married was very similar (Figure 14). There was a slightly larger proportion of males who were never married or civil partnered, and slightly smaller proportion of divorced or widowed men than women.

Suicide and relationship status

Figure 14: Distribution of relationship status among men and women who died by suicide in Norfolk.

Relationship problems were an identified risk factor in 32% of inquest files reviewed, both for males and females. This was often accompanied by related risk factors such as experience of domestic abuse as a victim or perpetrator, or issues and worries about losing access to one’s children.

Risk factors that change with age

An academic study on 100 suicides identified age-specific risk factors characterised by “young people in crisis, mid-life gendered patterns of work and family, and older people in decline”²⁴. The Coroner Inquest Files reviewed in Norfolk were in broad agreement with those findings (Figure 15). Mental health and social problems were common risk factors among all age groups. In the youngest age group, adverse experiences (30%) were relatively more prevalent than in other age groups. Among young and middle-aged adults, notable risk factors which were more prevalent than for other age groups were related to material problems (financial, employment, housing) as well as crime (as a victim or perpetrator). Among a substantial percentage of individuals aged 60 years and older, physical health was known or thought to have been a major contributory factor (74%). Poor physical health is a known risk factor for suicide²⁵.

Suicide risk factors by age

Figure 15: Bar chart on the prevalence of risk factor groups among Norfolk suicides for four broad age groups. Mental health was the most prevalent risk factor across all age groups. Physical health, adverse experiences and addiction showed clear age trends, with physical health being a more prevalent risk factor later in life, and adverse experiences and addiction decreasing in prevalence with age.

Risk factors related to mental ill health

NICE evidence shows that “Depression is the leading cause of suicide, accounting for two-thirds of all deaths by suicide.” Especially in combination with chronic physical health problems, depression is a common mental health problem.

There has been a steady increase of the proportion of patients recorded on practice disease registers with depression and serious mental health issues (schizophrenia, bipolar affective disorder and other psychoses) in Norfolk, regionally and nationally in the last ten years (Figure 16). In 2022/23, more than 12% of patients were recorded as having depression and close to 1% were recorded as having serious mental illness in Norfolk. The increasing trend is not reflected in the prevalence of people with a low worthwhile score, which showed a spike in the first year of the Covid-19 pandemic but has since decreased to below 4% in Norfolk.

Benchmarking mental health risk factors

Figure 16: Distribution of relationship status among men and women who died by suicide in Norfolk.

Poor mental health was explicitly mentioned as an factor likely contributing to suicide for the vast majority of Norfolk inquest files reviewed for this suicide audit (Figure 13 & Figure 15). Sources for this varied between informal accounts from friends and family to reports from primary care and from mental health services.

Forty-one individuals (20%) had no diagnosed mental health disorders recorded. However, many individuals had one or several mental health diagnoses. Of the 202 individuals whose inquest files were reviewed, 161 (80%) had a diagnosed mental health disorder, with 32 individuals (16%) diagnosed with severe mental illness (SMI) which means at least one diagnosis of schizophrenia spectrum and other psychotic disorders or bipolar and related disorders (Figure 17 & Table 4). The majority of individuals (129; 64%) did not have an SMI diagnosis but had at least one other mental health diagnosis.

The most common conditions recorded for both females and males were depressive disorders with 122 (60%) individuals diagnosed with a form of this disorder. The second most recorded conditions were anxiety disorders, with 81 individuals (40%) diagnosed with a form of this disorder. A higher proportion of females (49%) had an anxiety disorder diagnosis, compared to males (37%), whereas the prevalence of a depression diagnosis was not different between the two sexes.

Of the 161 individuals with a diagnosed mental health disorder, 38% had one diagnosed condition, 44% had two diagnosed conditions and 18% had three or more diagnosed conditions.

Figure

Mental health diagnoses

Figure 17: Diagnoses of mental health conditions among a sample of individuals who died by suicide in Norfolk. Many individuals had multiple diagnoses recorded.

Table

Table 4: Diagnoses of mental health conditions among a sample of individuals who died by suicide in Norfolk. Many individuals had multiple diagnoses recorded.

Diagnosis	Number of individuals
Depressive Disorders	122
Anxiety Disorders	81
Schizophrenia Spectrum and Other Psychotic Disorders	25
Personality Disorders	14
Sleep- Wake Disorders	12
Substance- Related and Addictive Disorders	11
Trauma- and Stressor- Related Disorders	11
Bipolar and Related Disorders	9
Other	7
Suicidal Thoughts and Behaviours	5

5 Service Contact

Individuals at risk of suicide may be identified and supported by a variety of different services such as general practitioner (GP) practices, mental health services, social services and various Voluntary Community and Social Enterprise organisations. At times, multiple organisations provide services to the same individual. Here we summarise information available, which mainly relates to interactions with GP practices and mental health services.

It is important to acknowledge that this audit is based on people who died by suicide. As such, the available information only gives us a view into individuals for whom the support through family, friends and services, no matter how extensive, was not able to prevent suicide. The majority of people in contact with services, including mental health services, do not die by suicide.

Appropriate interventions for suicide prevention are not always in secondary or tertiary care. NICE guidance highlights the importance of community interventions and support. Research emphasises the benefit of a public health approach of tackling determinants of suicide (including wider determinants) on a population level. To help improve suicide prevention efforts, where it is possible and appropriate to do so, the voices of service users, families of those who have been affected, and those bereaved by suicide should be encouraged to contribute to shaping the actions of local partnerships.

5.1 Contact with GP (primary care) and mental health services (secondary care)

Recent research showed that patients in Wales who were in contact with mental health services who died by suicide had fewer contacts with their GP than patients who did not die by suicide, potentially indicating reduced access to or engagement with services by those who died by suicide. However, patients who died by suicide had more emergency hospital attendances. Especially self-harm related contacts with GPs and emergency departments as well as hospital admissions were much more prevalent among patients who died by suicide than among patients who didn’t.

The information from the coroner inquest files showed that a high proportion (85%) of people who died by suicide had been in contact with general practice in the year before their death (Figure 18), around half of whom in the month before their death (44% of all deaths), and one in four of whom (21% of all deaths) the week before their death.

A little more than half of people who died by suicide had attended secondary services in hospital in the year before their death. Around one in five had been seen in hospital in the last month of their life (Figure 18). For around one in four of those who had a known contact, the last contact with a hospital was explicitly related to suicidal ideation (most commonly suicide attempts by means of overdose; data not shown). Around one in three had no known contact with a hospital.

Fewer than half of the people who died by suicide had been in contact with mental health services in the year before their death (Figure 18). For almost half, there was no information indicating they were known to mental health services at all.

Last contact with health professionals

Figure 18: Time since the most recent contact with primary care (GP Surgery), secondary health services (hospitals) and mental health (MH) services, based on information in Coroner Inquest Files (N = 202)

Many individuals appear to have had intense support from health services (Figure 19):

• Sixty (30%) individuals who died by suicide had contact with their GP in the year before their death, discussed mental health problems with their GP, had been offered a referral to mental health (MH) services, and had contact with those services.

• A further 30 individuals had mental health relevant contacts with their GP and MH services.

• Another 24 were supported with their mental health by their GP, without having contact with MH services or being offered referral to MH services.

For other individuals, contacts with services were more limited:

• Forty-one (20%) individuals had contact with their GP in the year before their death but did not discuss mental health issues.

• 18 had contacts with GP and MH services, but GP contacts were limited to physical health issues. A further 11 had MH service contact but no GP contact.

• Five had contact with their GP with mental health relevance and were offered a referral to MH services but did not subsequently have contact with MH services.

• 13 individuals neither had contact with their GP, nor did they have MH service contact.

For just over half (56%) of the people who had talked to primary care about mental health issues, there was an explicit offer made from primary care to refer to mental health services. For around half of those who were not offered a referral after discussing mental health problems, the reason for not referring appears to have been that the patient was already know to mental health services. Overall, this means that around one in six people who died by suicide had been offered a referral into mental health services through their GP in the year before their death.

Contacts with health professionals

Figure 19: Incidence of combinations presence and nature of contact with primary care, with mental health services, and whether a referral from primary care to mental health services was made. Connected dots illustrate the combination of factors present. Vertical bars show the number of individuals with that specific combination of factors. Horizontal bars show the number of individuals with a particular factor present.

The frequency of contacts with a mental health relevance which individuals had with primary care in the year before their death was associated with whether they had a diagnosed severe mental illness, some other mental health diagnosis, or no diagnosed mental illness (Figure 20). A higher proportion of individuals with a severe mental illness had a high level of contact with their GP service regarding their mental health (i.e., five or more appointments) at 44%, compared to those with any other mental illness at 30% and those with no known mental condition at 2%.

Mental health contacts with Primary Care

Figure 20: Distribution of the number of contacts with a mental health relevance with primary care for individuals who died by suicide in Norfolk who had a severe mental illness, any other mental health diagnosis or no mental health diagnosis. Numbers indicate the number of individuals. We have not suppressed numbers here, to allow the distinction between no contact and unknown level of contact.

Most of the 32 individuals with an SMI diagnosis were somewhat frequently in contact with primary care for mental health reasons. Research shows that patients with severe mental illness (SMI) have more contacts with their GP practice than matched patients without SMI. Moreover, there was a trend towards increasing contacts for those with SMI that was not seen in other patients, at least up to 2012. Patients with SMI also show higher use of non-psychiatric services, are admitted as non-psychiatric inpatients more, have longer hospital stays and are more likely to be re-admitted to hospital²⁶.

Individuals with mental health conditions outside of the SMI definition, had lower rates of contact with their GP for mental health reasons, but this group made up the majority of individuals who died by suicide. As seen in Figure 17, depression and anxiety disorders were the most frequent formal diagnoses among individuals who died by suicide in Norfolk.

The majority of individuals who did not have a formally diagnosed mental health condition were not in contact with primary care for MH reasons in the year before their death. For a substantial minority of 49 individuals (30%) who had a diagnosed severe or other mental health condition, there was no evidence from the inquest files of any contact with primary care for mental health reasons in the year before their death (Figure 20). These individuals represent a potential opportunity for more effective suicide prevention through primary care.

The 35 individuals who had no diagnosed mental health condition and had not been in contact with primary care for mental health reasons represent a potential for improved access to support.

Further inspection shows that these individuals were on average around ten years older (60 vs 50 years old), relatively more were 70 years or older (43% vs 16%), more were often male (86% vs 71%) compared to those with a mental health diagnosis and/or MH contact with primary care. While some had had no recorded interactions with services, 74% had contact with primary care for physical health issues in the year before their death, 60% had secondary care contacts, 23% had some recorded contact with the criminal justice system, representing potential points of contact into support services. A substantial minority of eight individuals also had some evidence in the inquest files for suicidal ideation prior to death, although for seven of these this was based on informal accounts by friends or relatives, and hence mostly unknown to services.

Medication

Overall, 124 individuals (61%) were prescribed one or more psychoactive substances in the 12 months prior to their death (Figure 21). A higher proportion of individuals with severe mental disorders were prescribed three or more psychoactive medications in the year prior to death, compared to those with any other mental health diagnosis. Most individuals with no known mental health diagnosis did not have any psychoactive medication prescribed. More than two thirds of individuals who had mental health diagnoses other than SMI were prescribed some psychoactive medication, but the distribution between being prescribed one, two or three or more substances was more even than for the other two groups of individuals.

Prescription of psychoactive substances

Figure 21: The number of psychoactive prescriptions in the last year of life for individuals who died by suicide in Norfolk who had a severe mental illness, any other mental health diagnosis or no mental health diagnosis. Numbers indicate the percentage of individuals in a given prescription category among those within a mental health diagnosis category. Small numbers were not suppressed.

Among substances prescribed, antidepressants like mirtazapine and citalopram were the most common medication prescribed to individuals who died by suicide in Norfolk. Women tended to have a higher prevalence of antidepressant prescribing: 64% of women and 51% of men had an antidepressant prescribed.

Prescriptions

Figure 22: The 15 medications with the highest prescription prevalence among individuals who died by suicide in Norfolk. Many individuals had multiple medications prescribed in the year before their death.

Two-thirds of individuals with a depression and/or anxiety diagnosis had one or more psychoactive substances prescribed in the year before their death (see Figure 21 in the next section); 52% had one or more selective serotonin reuptake inhibitors (SSRIs) prescribed to them. NICE guidance emphasises the importance of a range of options for first line treatment; avoiding an over-reliance on anti-depressants and reviewing the impact of treatment regularly, especially in the first few weeks of prescribing anti depressants.

It should however be noted that among individuals who died by suicide and who had an antidepressant prescribed, only a small proportion (27%) died by self-poisoning, and an even smaller proportion (8%) died by self-poisoning by overdosing on the prescribed antidepressant (analyses combining data from the 2022 and 2024 Audits; data not shown).

Conversely, among those who died by self-poisoning, 59% of individuals had an antidepressant prescribed, compared to 50% of individuals who died by any other suicide method (analyses combining data from the 2022 and 2024 Audits; data not shown).

Contact with mental health services

Contact with mental health services in Norfolk was most prevalent and most intense for individuals with a severe mental illness. The majority had been in sustained contact at their last contact with mental health services (Figure 23). In contrast, the majority of individuals with no mental health diagnosis had no known contact with mental health services. Fewer than one in five among those with no or other mental health diagnoses had sustained or infrequent contact.

Contact with mental health services

Figure 23: Distribution of the nature of the last contact with mental health services for individuals who died by suicide in Norfolk who had a severe mental illness, any other mental health diagnosis or no mental health diagnosis. Numbers indicate the number of individuals. Small numbers were not suppressed.

The prevalence of a history of psychiatric inpatient care also aligned with mental health diagnoses severity. 50% of those with a diagnosed severe mental illness had a psychiatric inpatient history, compared to 16% of those with any other mental health diagnosis and 2% of those with no recorded mental health diagnosis. Research has identified an elevated suicide risk after discharge from inpatient care especially when there is no follow-up with primary care in the first two weeks after discharge, when individuals were prescribed more psychotropic medications, and when individuals had mental health diagnoses outside the severe mental illness definition.

Service contacts with men

As acknowledged in the national and local suicide prevention strategies, middle-aged men have among the highest suicide rates and are a particular priority cohort for suicide prevention efforts. A study published in 2023 identified potential indications of subsequent suicides from men’s interactions with their GP. It identified having a major physical illness, recent self-harm, presenting with a mental health problem, and recent work-related issues as factors that GPs should be especially alert to when assessing middle-aged males.

Men are generally thought to have lower levels of health-seeking behaviour. There is evidence to support this when it comes to the general population’s preferences for psychological therapies. For example, men expressed a stronger liking for support groups than women did. A study on UK patients found that generally men had fewer interactions with primary care than women. But when focusing on those patients with a diagnosis of depression or with prescribed anti-depressant medication, men and women had similar levels of interaction with primary care, particularly after interactions for reasons related to reproductive health were removed from the dataset. Similarly, only a minority of middle-aged men were not in contact with any services in a national study on data from 2017. In the sample of Coroner Inquest Files reviewed for this audit, there were no pronounced differences in health-seeking behaviour between men and women.

6 Impacts of the Covid-19 pandemic

In Coroner Inquest Files, negative impacts of Covid-19 which were thought to have potentially contributed to the suicide as a risk factor was explicitly mentioned in 25 (13%) out of 196 deaths since the beginning of the Covid-19 pandemic in March 2020.

There is no evidence that the Covid-19 pandemic has increased suicide rates in England, at least in the early phases of the pandemic (ONS, 2022). Research based on real-time surveillance systems covering around a quarter of the population of England showed that from April to December 2020, suicide rates were actually lower for men aged 25-44 than they had been pre-pandemic.

It is still unclear whether and to what extent the pandemic has had an impact on suicide rates in the longer term, for example through disruption of education and jobs, psychological distress, or long Covid. Financial hardship was a direct impact of Covid-19 for some, and for many has been compounded by the cost of living crisis. The impact of the 2008-2010 financial recession on suicide rates demonstrates how cost of living challenges can have significant implications.

Footnotes

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2. Pitman, A., Osborn, D., King, M., & Erlangsen, A. (2014). Effects of suicide bereavement on mental health and suicide risk. The Lancet Psychiatry. The Lancet Psychiatry, 1(1), 86-94.

3. Office for National Statistics. (2023, December). Suicides in the United Kingdom: 2022 registrations.

4. Office for National Statistics. (2020). Change in the standard of proof used by coroners and the impact on suicide death registrations data in England and Wales.

5. Palmer, B. S., Bennewith, O., Simkin, S., Cooper, J., Hawton, K., Kapur, N., & Gunnell, D. (2015). Factors influencing coroners’ verdicts: An analysis of verdicts given in 12 coroners’ districts to researcher-defined suicides in England in 2005. Journal of Public Health, 37(1), 157-165.

6. Katz C, Bolton J, Sareen J. The prevalence rates of suicide are likely underestimated worldwide: why it matters. Social Psychiatry and Psychiatric Epidemiology. 2016;51(1):125. doi:10.1007/s00127-015-1158-3.

7. Snowdon, J. (2021). Comparing rates and patterns of male suicide and “hidden suicide” between nations and over time. Journal of Men’s Health, 17(4), 7-16.

8. Langer, S., Scourfield, J., & Fincham, B. (2008). Documenting the quick and the dead: A study of suicide case files in a coroner’s office. The Sociological Review, 56(2), 293-308.

9. Mallon, S., Galway, K., Hughes, L., & Rondón-Sulbarán, J. (2016). An exploration of integrated data on the social dynamics of suicide among women. Sociology of Health and Illness, 38(4), 662-675.

10. World Health Organization (2021). Suicide worldwide in 2019: global health estimates.

11. Turecki, G., Brent, D. A., Gunnell, D., O’Connor, R. C., Oquendo, M., Pirkis, J., & Stanley, B. H. (2019). Suicide and suicide risk. Nat Rev Dis Primers 5, 74 (2019). Nature Reviews Disease Primers, 5, 74.

12. Pirkis, J., Dandona, R., Silverman, M., Khan, M. & Hawton, K. (2024). Preventing suicide: a public health approach to a global problem. The Lancet Public Health, Volume 9, Issue 10, e787 - e795

13. Office for National Statistics (2019). The English Indices of Deprivation 2019 (IoD2019).

14. Norfolk County Council. (2023). Norfolk’s Story.

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16. Camacho, C., Webb, R. T., Bower, P., & Munford, L. (2024). Risk factors for deaths of despair in England: An ecological study of local authority mortality data. Social Science & Medicine, 342, 116560.

17. Milner, A., Page, A., & LaMontagne, A. D. (2013). Long-Term Unemployment and Suicide: A Systematic Review and Meta-Analysis. PLoS ONE, 8(1), e51333.

18. Hirvikoski, T., Mittendorfer-Rutz, E., Boman, M., Larsson, H., Lichtenstein, P., & Bölte, S. (2016). Premature mortality in autism spectrum disorder. The British Journal of Psychiatry, 208(3), 232-238.

19. Cassidy, S., Au-Yeung, S., Robertson, A., Cogger-Ward, H., Richards, G., Allison, C., … & Baron-Cohen, S. (2022). Autism and autistic traits in those who died by suicide in England. The British Journal of Psychiatry, 221(5), 683-691.

20. Pitman, A., Osborn, D., King, M., & Erlangsen, A. (2014). Effects of suicide bereavement on mental health and suicide risk. The Lancet Psychiatry, 1(1), 86-94.

21. Molina, N., Viola, M., Rogers, M., Ouyang, D., Gang, J., Derry, H., & Prigerson, H. G. (2019). Suicidal Ideation in Bereavement: A Systematic Review. Behavioral Sciences, 9(5), 53.

22. Scourfield, J., & Evans, R. (2015). Why Might Men Be More at Risk of Suicide After a Relationship Breakdown? Sociological Insights. American Journal of Mens Health, 9(5), 380-384.

23. Evans, R., Scourfield, J., & Moore, G. (2016). Gender, Relationship Breakdown, and Suicide Risk: A Review of Research in Western Countries. Journal of Family Issues, 37(16), 2239-2264.

24. Shiner , M., Scourfield, J., Fincham, B., & Langer, S. (2009). When things fall apart: Gender and suicide across the life-course. Social Science and Medicine, 69(5), 738-746.

25. Leahy, D., Larkin, C., Leahy, D., McAuliffe, C., Corcoran, P., Williamson, E., & Arensman, E. (2020). The mental and physical health profile of people who died by suicide: findings from the Suicide Support and Information System. Social Psychiatry and Psychiatric Epidemiology, 55(11), 1525-1533.

26. Ronaldson, A., Elton, L., Jayakumar, S., Jieman, A., Halvorsrud, K., & Bhui, K. (2020). Severe mental illness and health service utilisation for nonpsychiatric medical disorders: a systematic review and meta-analysis. PLoS medicine, 17(9), e1003284.