Alison Roscoe

Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: a cross-sectional and before-and-after observational study

BACKGROUND Research investigating which aspects of mental health service provision are most effective in prevention of suicide is scarce. We aimed to examine the uptake of key mental health service recommendations over time and to investigate the association between their implementation and suicide rates. METHODS We did a descriptive, cross-sectional, and before-and-after analysis of national suicide data in England and Wales. We collected data for individuals who died by suicide between 1997 and 2006 who were in contact with mental health services in the 12 months before death. Data were obtained as part of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. When denominator data were missing, we used information from the Mental Health Minimum Data Set. We compared suicide rates for services implementing most of the recommendations with those implementing fewer recommendations and examined rates before and after implementation. We stratified results for level of socioeconomic deprivation and size of service provider. FINDINGS The average number of recommendations implemented increased from 0·3 per service in 1998 to 7·2 in 2006. Implementation of recommendations was associated with lower suicide rates in both cross-sectional and before-and-after analyses. The provision of 24 h crisis care was associated with the biggest fall in suicide rates: from 11·44 per 10 000 patient contacts per year (95% CI 11·12-11·77) before to 9·32 (8·99-9·67) after (p<0·0001). Local policies on patients with dual diagnosis (10·55; 10·23-10·89 before vs 9·61; 9·18-10·05 after, p=0·0007) and multidisciplinary review after suicide (11·59; 11·31-11·88 before vs 10·48; 10·13-10·84 after, p<0·0001) were also associated with falling rates. Services that did not implement recommendations had little reduction in suicide. The biggest falls in suicide seemed to be in services with the most deprived catchment areas (incidence rate ratio 0·90; 95% CI 0·88-0·92) and the most patients (0·86; 0·84-0·88). INTERPRETATION Our findings suggest that aspects of provision of mental health services can affect suicide rates in clinical populations. Investigation of the relation between new initiatives and suicide could help to inform future suicide prevention efforts and improve safety for patients receiving mental health care. FUNDING National Patient Safety Agency, UK.

Homicide followed by suicide: a cross-sectional study

Background: Approximately 30 incidents of homicide followed by suicide occur in England and Wales each year. Previous studies have not examined mental health characteristics in any detail. Aims: This study aims to identify the social, clinical, and criminological characteristics of a national sample of perpetrators, to identify any previous contact with mental health services and to establish risk of suicide after homicide. Method: A national cross-sectional study of perpetrators in England and Wales 1996–2005. Results: 203 incidents were recorded over 9 years. The median age of perpetrators was 41 years (range 18–88 years); most were male. Men more often killed a spouse/partner, whilst women more commonly killed their children. Eighty-four (42%) perpetrators died by suicide on the day of the homicide. The most common method of homicide was sharp instrument (44, 23%). Fifty-nine (29%) used hanging as a method of suicide. Twenty (10%) had previous contact with mental health services, 14 were seen within a year of the offence. The most common diagnoses were personality disorder and affective disorder. The risk of suicide increased the closer the relationship between the perpetrator and the victim. Conclusions: Significantly fewer perpetrators of homicide-suicide compared with homicide or suicide only were in contact with mental health services. Prevention is discussed and suggestions made for the use of psychological autopsy methodology to study rates of mental disorder.

A Population-Based Study of Juvenile Perpetrators of Homicide in England and Wales.

This study aimed to describe the social, behavioural and offence characteristics of all convicted perpetrators of homicide aged 17 and under; to examine their previous contact with mental health services, and to discuss strategies for homicide prevention. An eight-year (1996-2004) sample of 363 juvenile homicide perpetrators in England and Wales was examined. The majority of perpetrators were male, used a sharp instrument, and most victims were acquaintances or strangers. Over half had previously offended. A history of alcohol and/or drug misuse was common, as was the prevalence of family dysfunction, abuse, educational difficulties or discipline problems. Previous contact with mental health services was rare. Earlier intervention targeting social and psychological adversity and substance misuse could help to reduce the level of risk for future violence, and may reduce homicide rates among juveniles. Strengthening engagement with young offenders and increasing resources to prevent recidivism may also be beneficial.

Trends in rates of mental illness in homicide perpetrators

BACKGROUND The rise in homicides by those with serious mental illness is of concern, although this increase may not be continuing. AIMS To examine rates of mental illness among homicide perpetrators. METHOD A national consecutive case series of homicide perpetrators in England and Wales from 1997 to 2006. Rates of mental disorder were based on data from psychiatric reports, contact with psychiatric services, diminished responsibility verdict and hospital disposal. RESULTS Of the 5884 homicides notified to the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness between 1997 and 2006, the number of homicide perpetrators with schizophrenia increased at a rate of 4% per year, those with psychotic symptoms at the time of the offence increased by 6% per year. The number of verdicts of diminished responsibility decreased but no change was found in the number of perpetrators receiving a hospital order disposal. The likeliest explanation for the rise in homicide by people with psychosis is the misuse of drugs and/or alcohol, which our data show increased at a similar magnitude to homicides by those with psychotic symptoms. However, we are unable to demonstrate a causal association. Although the Poisson regression provides evidence of an upward trend in homicide by people with serious mental illness between 1997 and 2006, the number of homicides fell in the final 2 years of data collection, so these findings should be treated with caution. CONCLUSIONS There appears to be a concomitant increase in drug misuse over the period, which may account for this rise in homicide. However, an increase in the number of people in contact with mental health services may suggest that access to mental health services is improving. Previous studies have used court verdicts such as diminished responsibility as a proxy measure of mental disorder. Our data indicate that this does not reflect accurately the prevalence of mental disorder in this population.

Comparison of British National Newspaper Coverage of Homicide Committed by Perpetrators with and Without Mental Illness

Objective: Adverse newspaper reporting of mental illness and in particular, violence committed by a mentally ill person, is thought to contribute to stigma. However, violent events are also considered highly newsworthy by journalists. The aim of this study was to compare the likelihood of newspaper reporting for convicted perpetrators of homicide with and without a history of contact with mental health services. Method: A 12 month (April 2000-March 2001) cohort of 577 homicide perpetrators with and without a history of contact with mental health services in England and Wales was examined. These cases were identified by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. By examining 12 national newspapers, we compared the likelihood of reporting homicide perpetrators with and without mental illness. Results: Under half (228 cases, 40%) of the homicide perpetrators were reported in at least one of the study newspapers. Under a fifth (94 cases, 16%) of perpetrators had a history of contact with mental health services and such previous contact did not increase the likelihood of newspaper reporting (odds ratio 1.0 (0.6–1.6)). Conclusions: Previous contact with mental health services did not influence the newsworthiness of a homicide perpetrator. The stigmatizing effect of reporting homicide by perpetrators with mental illness may relate more to the quality of reporting rather than selective over-reporting.

Homicide perpetrated by older people

This study aims to describe the circumstances in which older people commit homicide, the form of assessment they undergo and to examine the proportion of those who suffer from mental illness.

Comparison of a national sample of homicides committed by lone and multiple perpetrators

Homicide committed by multiple perpetrators is an understudied area and there has been no research investigating psychiatric differences between multiple and lone perpetrators of homicide. The objective of this study was to explore the demographic, criminological and psychiatric differences of the victims and perpetrators of multiple perpetrator homicides and compare them with the victims and perpetrators of lone perpetrator homicides. A 10-year (1997–2006) consecutive national sample of homicide perpetrators in England and Wales was used in this study. Of the 5806 homicides identified, 1485 were perpetrated by two or more convicted offenders. Convicted perpetrators who engaged in multiple perpetrator homicide were younger and single and less likely to be mentally ill at the time of the offence. It is concluded that supportive services should be provided for young people to reduce the rate of multiple perpetrator homicide.

Methods of homicide in England and Wales: a comparison by diagnostic group

Background: International literature has examined the offence characteristics of homicide in the general population, but there has been limited research investigating diagnostic differences between perpetrators who commit homicide by differing methods. Objective: To investigate the methods of homicide by people with different psychiatric diagnoses and to explore the offence characteristics of perpetrators with schizophrenia, in a seven-year (1997–2003) national sample of homicide perpetrators in England and Wales. Results: Of the 3930 homicide perpetrators identified, over a third (36%) used a sharp instrument. The use of firearms was rare. Methods of homicide differed significantly between diagnostic groups. Perpetrators with schizophrenia were more likely to use a sharp instrument and predominantly killed a family member or spouse in the home; a significant majority were mentally ill at the time of the offence. Perpetrators diagnosed with affective disorder were more likely to use strangulation or suffocation. Alcohol dependent perpetrators used hitting or kicking significantly more often, primarily to kill acquaintances. Finally, drug dependent perpetrators were more likely to use non-violent methods, particularly poisoning. Conclusion: Methods of homicide are affected not only by the social and behavioural characteristics of the perpetrator and victim, but also by the perpetrators psychiatric history and diagnosis.

Services for released prisoners should address the many causes of reoffending.

www.thelancet.com/psychiatry Vol 2 October 2015 853 in fi ndings between programmes and inform thinking about the transferability and implementation of CTO policies. Policy decisions about whether and how to implement CTOs will continue to be challenging. Such deliberations are continuing in several US states, and proposed federal legislation in the USA would incentivise states to implement them. Whatever benefi ts or drawbacks CTOs might bring, they only aff ect a few people with serious mental illnesses. Although the policy could help to conserve public funds, CTOs alone cannot fi x the structural problems of an under-resourced mental health-care system. For now, CTOs are reasonable policies if targeted to the correct people and thoughtfully implemented, and for which providers are reciprocally committed to the treatment plan and there is adequate capacity for appropriate and sustained care. Under those conditions, CTOs could make eff ective treatment much more consistently available to those few individuals with mental illness who are in most need of treatment, but in the real world might not receive treatment any other way. *Marvin S Swartz, Jeff rey W Swanson Box 3173, Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Duke University Medical Center, Durham, NC 27710, USA (MSS, JWS) marvin.swartz@duke.edu

Homicide convictions in different age-groups: a national clinical survey

The purpose of this study was to examine the social, clinical and forensic characteristics of all convicted homicide perpetrators by different age-groups over an 8-year period (1997–2004) in England and Wales. Perpetrators aged under 25 were more likely to use hitting or kicking compared to other offenders, and their victims were more often young, male and a stranger. In contrast, perpetrators aged 65 and over were most likely to use strangulation/suffocation and the victim was more often a female and a family member or spouse. In younger perpetrators, drug and alcohol misuse and previous violence were more common. Older perpetrators had high rates of affective disorder and were more likely to be mentally ill at the time of the offence. Targeting substance and alcohol misuse and street violence may reduce homicide risk in younger people. Preventing homicide among the elderly might be best achieved through more specialised GP training to improve recognition and treatment of depression.