Cameron Stark

Trends in suicide in Scotland 1981 – 1999: age, method and geography

BackgroundMale suicide rates continued to increase in Scotland when rates in England and Wales declined. Female rates decreased, but at a slower rate than in England and Wales. Previous work has suggested higher than average rates in some rural areas of Scotland. This paper describes trends in suicide and undetermined death in Scotland by age, gender, geographical area and method for 1981 – 1999.MethodsDeaths from suicide and undetermined cause in Scotland from 1981 – 1999 were identified using the records of the General Registrar Office. The deaths of people not resident in Scotland were excluded from the analysis. Death rates were calculated by area of residence, age group, gender, and method. Standardised Mortality Ratios (SMRs) and 95% confidence intervals were calculated for rates by geographical area.ResultsMale rates of death by suicide and undetermined death increased by 35% between 1981 – 1985 and 1996 – 1999. The largest increases were in the youngest age groups. All age female rates decreased by 7% in the same period, although there were increases in younger female age groups.The commonest methods of suicide in men were hanging, self-poisoning and car exhaust fumes. Hanging in males increased by 96.8% from 45 per million to 89 per million, compared to a 30.7% increase for self-poisoning deaths. In females, the commonest method of suicide was self-poisoning. Female hanging death rates increased in the time period.Male SMRs for 1981 – 1999 were significantly elevated in Western Isles (SMR 138, 95% CI 112 – 171), Highland (135, CI 125 – 147), and Greater Glasgow (120, CI 115 – 125). The female SMR was significantly high only in Greater Glasgow (120, CI 112 – 128).ConclusionAll age suicide rates increased in men and decreased in women in Scotland in 1981 – 1999. Previous findings of higher than expected male rates in some rural areas were supported. Rates were also high in Greater Glasgow, one of the most deprived areas of Scotland. There were changes in the methods used, with an increase in hanging deaths in men, and a smaller increase in hanging in women. Altered choice of method may have contributed to the increased male deaths.

Reduction in young male suicide in Scotland

BackgroundRates of suicide and undetermined death increased rapidly in Scotland in the 1980s and 1990s. The largest increases were in men, with a marked increase in rates in younger age groups. This was associated with an increase in hanging as a method of suicide. National suicide prevention work has identified young men as a priority group. Routinely collected national information suggested a decrease in suicide rates in younger men at the beginning of the 21st century. This study tested whether this was a significant change in trend, and whether it was associated with any change in hanging rates in young men.MethodsJoinpoint regression was used to estimate annual percentage changes in age-specific rates of suicide and undetermined intent death, and to identify times when the trends changed significantly. Rates of deaths by method in 15 – 29 year old males and females were also examined to assess whether there had been any significant changes in method use in this age group.ResultsThere was a 42% reduction in rates in 15 – 29 year old men, from 42.5/100,000 in 2000 to 24.5/100,000 in 2004. A joinpoint analysis confirmed that this was a significant change. There was also a significant change in trend in hanging in men in this age group, with a reduction in rates after 2000. No other male age group showed a significant change in trend over the period 1980 – 2004. There was a smaller reduction in suicide rates in women in the 15 – 29 year old age group, with a reduction in hanging from 2002.ConclusionThere has been a reduction in suicide rates in men aged 15 – 29 years, and this is associated with a significant reduction in deaths by hanging in this age group. It is not clear whether this is related to a change in method preference, or an overall reduction in suicidal behaviour, and review of self-harm data will be required to investigate this further.

The epidemiology of hospital treated traumatic brain injury in Scotland

BackgroundTraumatic Brain Injury (TBI) is an important global public health problem made all the more important by the increased likelihood of disability following a hospital admission for TBI. Understanding those groups most at risk will help inform interventions designed to prevent causes of TBI, such as falls prevention measures. This study identifies the rate of hospitalisation episodes of TBI in Scotland, explores causes of TBI admissions, and trends in hospitalisation episodes by age and gender over a twelve year period using routinely collected hospital data.MethodsA retrospective analysis of routine hospital episode data identified records relating to TBI for the twelve years between 1998 and 2009. Descriptive and joinpoint regression analysis were used, average annual percentage changes (AAPC) and annual percentage change (APC) in rates were calculated.ResultsBetween 1998 and 2009 there were 208,195 recorded episodes of continuous hospital care in Scotland as a result of TBI. Almost half (47%) of all TBIs were the result of falls, with marked peaks observed in the very young and the oldest groups. The AAPC of hospitalization episode rates over the study period for boys and girls aged 0-14 were -4.9% (95% CI -3.5 to-6.3) and -4.7% (95% CI -2.6 to -6.8) respectively. This reduction was not observed in older age groups. In women aged 65 and over there was an APC of 3.9% (95% CI 1.2 to 6.6) between 2004 and 2009.ConclusionsHospitalisation for TBI is relatively common in Scotland. The rise in the age-adjusted rate of hospitalisation episodes observed in older people indicates that reduction of TBI should be a public health priority in countries with an ageing population. Public health interventions such as falls prevention measures are well advised and evaluations of such interventions should consider including TBI hospitalisation as an alternative or supplementary outcome measure to fractured neck of femur. Further research is needed to advance understanding of the associations of risk factors with increased incidence of TBI hospital episodes in the elderly population.

Family size and perinatal circumstances, as mental health risk factors in a Scottish birth cohort

PurposeHigher maternal parity and younger maternal age have each been observed to be associated with subsequent offspring suicidal behaviour. This study aimed to establish if these, and other variables from the perinatal period, together with family size, are also associated with other psychiatric morbidity.MethodsLinked datasets of the Scottish Morbidity Record and Scottish death records were used to follow up, into young adulthood, a birth cohort of 897,685. In addition to the index maternity records, mothers’ subsequent pregnancy records were identified, allowing family size to be estimated. Three independent outcomes were studied: suicide, self-harm, and psychiatric hospital admission. Data were analysed using Cox regression.ResultsYounger maternal age and higher maternal parity were independently associated with increased risk in offspring of suicide, of self-harm and of psychiatric admission. Risk of psychiatric admission was higher amongst those from families of three or more, but, compared with only children, those with two or three siblings had a lower risk of self harm.ConclusionPerinatal and family composition factors have a broad influence on mental health outcomes. These data suggest that the existence of younger, as well as elder siblings may be important.

Mortality after discharge from long-term psychiatric care in Scotland, 1977-94: a retrospective cohort study.

BackgroundRecent United Kingdom strategies focus on preventable suicide deaths in former psychiatric in-patients, but natural causes of death, accidents and homicide may also be important. This study was intended to find the relative importance of natural and unnatural causes of death in people discharged from long-term psychiatric care in Scotland in 1977 –1994.MethodsPeople discharged alive from psychiatric hospitals in Scotland in 1977 – 94 after a stay of one year or longer were identified using routine hospital records. Computer record linkage was used to link hospital discharges to subsequent death records. Mortality was described using a person-years analysis, and compared to the general population rates.Results6,776 people were discharged in the time period. 1,994 people (29%) died by the end of follow-up, 732 more deaths than expected. Deaths from suicide, homicide, accident and undetermined cause were increased, but accounted for only 197 of the excess deaths. Deaths from respiratory disease were four times higher than expected, and deaths from other causes, including cardiovascular disease, were also elevated.ConclusionSuicide is an important cause of preventable mortality, but natural causes account for more excess deaths. Prevention activities should not focus only on unnatural causes of death.

Perinatal and psychosocial circumstances associated with risk of attempted suicide, non-suicidal self-injury and psychiatric service use. A longitudinal study of young people

BackgroundPast studies using large population based datasets link certain perinatal circumstances (birth weight, parity, etc) with mental health outcomes such as suicide, self-harm and psychiatric problems. Problematically, population datasets omit a number of social confounds. The aim of this study is to replicate past research linking perinatal circumstances and mental health (suicidality and use of psychiatric services) and to determine if such associations remain after adjusting for social circumstances.MethodsA longitudinal school-based survey of 2157 young people (surveyed at age 11, 13, 15) followed up in early adulthood (age 19). At age 11 parents of participants provided information about perinatal circumstances (birth weight, birth complications, etc.) and psychiatric service use. Participants provided data about their mental health at age 15 (attempted suicide, suicidal thoughts) and at ages 19 (self-harm, psychiatric service use). In addition, data were collected about their social and psychosocial circumstances (gender, deprivation, religion, sexual behaviour, etc.).ResultsPredictably, social factors were linked to mental health outcomes. For example, those with same sex partners were more likely (OR 4.84) to self-harm than those without a same sex partner. With a single exception, in both unadjusted and adjusted models, perinatal circumstances were not or only marginally associated with mental health outcomes. The exception was the number of birth complications; young people with two or more complications were approximately 2-3 times more likely than those without complications to use psychiatric services.ConclusionsWhile we failed to replicate results found using large population based datasets, some of our results are compatible with prior research findings. Further, evidence from this study supports the influence of perinatal circumstances (birth complications) on later psychiatric problems, or at least higher than expected contact with psychiatric service.

Changes in Scottish suicide rates during the Second World War

BackgroundIt is believed that total reported suicide rates tend to decrease during wartime. However, analysis of suicide rates during recent conflicts suggests a more complex picture, with increases in some age groups and changes in method choice. As few age and gender specific analyses of more distant conflicts have been conducted, it is not clear if these findings reflect a change in the epidemiology of suicide in wartime. Therefore, we examined suicide rates in Scotland before, during and after the Second World War to see if similar features were present.MethodsData on deaths in Scotland recorded as suicide during the period 1931 – 1952, and population estimates for each of these years, were obtained from the General Register Office for Scotland. Using computer spreadsheets, suicide rates by gender, age and method were calculated. Forward stepwise logistic regression was used to assess the effect of gender, war and year on suicide rates using SAS V8.2.ResultsThe all-age suicide rate among both men and women declined during the period studied. However, when this long-term decline is taken into account, the likelihood of suicide during the Second World War was higher than during both the pre-War and post-War periods. Suicide rates among men aged 15–24 years rose during the Second World War, peaking at 148 per million (41 deaths) during 1942 before declining to 39 per million (10 deaths) by 1945, while the rate among men aged 25–34 years reached 199 per million (43 deaths) during 1943 before falling to 66 per million (23 deaths) by 1946. This was accompanied by an increase in male suicides attributable to firearms and explosives during the War years which decreased following its conclusion.ConclusionAll age male and female suicide rates decreased in Scotland during World War II. However, once the general background decrease in suicide rates over the whole period is accounted for, the likelihood of suicide among the entire Scottish population during the Second World War was elevated. The overall decrease in suicide rates concealed large increases in younger male age groups during the War years, and an increase in male suicides recorded as due to the use of firearms. We conclude that the effects of war on younger people, reported in recent conflicts in Central Europe, were also seen in Scotland during the Second World War. The results support the findings of studies of recent conflicts which have found a heterogeneous picture with respect to age specific suicide rates during wartime.

Community hospitals – the place of local service provision in a modernising NHS: an integrative thematic literature review

BackgroundRecent developments within the United Kingdoms (UK) health care system have re-awakened interest in community hospitals (CHs) and their role in the provision of health care. This integrative literature review sought to identify and assess the current evidence base for CHs.MethodsA range of electronic reference databases were searched from January 1984 to either December 2004 or February 2005: Medline, Embase, Web of Knowledge, BNI, CINAHL, HMIC, ASSIA, PsychInfo, SIGLE, Dissertation Abstracts, Cochrane Library, Kings Fund website, using both keywords and text words. Thematic analysis identified recurrent themes across the literature; narrative analyses were written for each theme, identifying unifying concepts and discrepant issues.ResultsThe search strategy identified over 16,000 international references. We included papers of any study design focussing on hospitals in which care was led principally by general practitioners or nurses. Papers from developing countries were excluded. A review of titles revealed 641 potentially relevant references; abstract appraisal identified 161 references for review. During data extraction, a further 48 papers were excluded, leaving 113 papers in the final review. The most common methodological approaches were cross-sectional/descriptive studies, commentaries and expert opinion. There were few experimental studies, systematic reviews, economic studies or studies that reported on longer-term outcomes. The key themes identified were origin and location of CHs; their place in the continuum of care; services provided; effectiveness, efficiency and equity of CHs; and views of patients and staff.In general, there was a lack of robust evidence for the role of CHs, which is partly due to the ad hoc nature of their development and lack of clear strategic vision for their future. Evidence for the effectiveness and efficiency of the services provided was limited. Most people admitted to CHs appeared to be older, suggesting that admittance to CHs was age-related rather than condition-related.ConclusionOverall the literature surveyed was long on opinion and short of robust studies on CHs. While lack of evidence on CHs does not imply lack of effect, there is an urgent need to develop a research agenda that addresses the key issues of health care delivery in the CH setting.

Primary care professionals’ knowledge and attitudes on speech disfluency in pre-school children

Early intervention in fluency disorders such as stammering is desirable but this depends on early referral of disfluent children to speech and language therapists. The willingness to refer young disfluent children depends on, among other things, the knowledge and attitudes of primary care practitioners who are likely to be the main sources of referral. A postal questionnaire survey was carried out of all general practitioners (GPs) and health visitors (HVs) in the area of the former Highland Community NHS Trust to elicit this information. The results indicated that these professionals were more likely to refer young disfluent children to speech and language therapy if they themselves had received some post-graduate training about this disorder. More GPs than HVs were uncertain about the natural history of the disorder and about whether young disfluent children should be enrolled for therapy. GPs were more inclined to believe that there were personality traits characteristic of those who stammer and they were also more influenced by waiting lists in their decisions about referral. It would seem that some primary care professionals may have beliefs about stammering which were acquired in their training and which have not been updated. Appropriate post-graduate training seems to increase referral numbers. Training programmes that meet the needs of primary care professionals should be supported and evaluated.

Interpretation of ecological data

We read the debate on antidepressants and suicide[1][1] with interest, especially the issue concerning the importance of controlling for possible confounding variables in ecological studies and the associated difficulties in drawing conclusions from such ecological observations. One potentially