David Gunnell

Prevention of suicide: aspirations and evidence

The Health of the Nation white paper set a target for 15% reduction in overall suicide rates by the year 2000. If the targets are to be achieved interventions must be identified which are of proved effectiveness. This paper examines the evidence on the available interventions and points of access to the population at risk. No single intervention has been shown in a well conducted randomised controlled trial to reduce suicide. The greatest potential seems to arise from limiting the availability of methods. In particular it is likely that the introduction of the catalytic convertor will lead to reduced lethality of care exhausts and reductions in suicide using this method. General practitioner education programmes, the effectiveness of lithium and maintenance antidepressants, and limits on the quantity of medicines available over the counter or on prescription should all be evaluated. Particular high risk groups include people recently discharged from psychiatric hospitals and those with a history of parasuicide. Many social processes affect suicide rates and these rather than specific interventions may help or hinder the ability to realise the Health of the Nation targets. Well conducted trials are essential to distinguish complex social processes from the effects of specific interventions for suicide prevention. This review of the available evidence offers little support for the aspiration that the posited targets can be achieved on the basis of current knowledge and current policy.

Height, wealth, and health: An overview with new data from three longitudinal studies

This overview, based on a literature review and new data from the three cohorts (Whitehall Studies I and II, and the Vietnam Experience Study), has four objectives: (a) to outline the major determinants of height, so providing an indication as to what exposures this characteristic may capture; (b) to summarise, by reviewing reports from large scale studies, the relation between adult height and a range of disease outcomes--both somatic and psychiatric--with particular emphasis on coronary heart disease (CHD) and stroke; (c) to discuss why these relationships may exist, in particular, the role, if any, of socioeconomic position in explaining the apparent associations; and, finally (d) to outline future research directions in this field. The large majority of evidence for predictors of height, and its health consequences, comes from observational studies. While genetic predisposition is a major determinant of height, secular rises in childhood and adult stature across successive birth cohorts suggest that early life environment also has an important impact. Plausible non-genetic determinants of height include nutrition, illness, socioeconomic status, and psychosocial stress. Evidence for an association between height and a series of health endpoints is accumulating. Thus, shorter people appear to experience increased risk of CHD, and these associations appear to be independent of socioeconomic position and other potentially confounding variables. For stroke, and its sub-types, findings are less clear. In contrast to CHD, some cancers, such as carcinoma of the colorectum, prostate, breast (in women), central nervous system, skin, endometrium, thyroid and blood (haematopoietic) are more common in taller people. While height may be negatively related to the risk of completed suicide, conclusions about the links between stature and other health endpoints is problematic given the paucity of evidence, which should be addressed. Ultimately, for want of better data, investigators in this area have used height as a proxy for a range of pre-adult exposures. In future, research should aim to explore the predictive capacity of direct measures of diet, psychosocial stress, childhood chronic illness and so on, rather than focus on height or its components. The problem is that extended follow-up of child cohorts with such data are required, and studies which hold these data are not currently available, although several are either maturing to the point where they offer sufficient clinical outcomes to facilitate analyses or are in the advanced planning stage.

Suicide and the internet

Recentreports of suicide by young people have highlighted the possible influence of internet sites. Lucy Biddle and colleagues investigate what a web search is likely to find

Hospital Presenting Self-Harm and Risk of Fatal and Non-Fatal Repetition: Systematic Review and Meta-Analysis

Background Non-fatal self-harm is one of the most frequent reasons for emergency hospital admission and the strongest risk factor for subsequent suicide. Repeat self-harm and suicide are key clinical outcomes of the hospital management of self-harm. We have undertaken a comprehensive review of the international literature on the incidence of fatal and non-fatal repeat self-harm and investigated factors influencing variation in these estimates as well as changes in the incidence of repeat self-harm and suicide over the last 30 years. Methods and Findings Medline, EMBASE, PsycINFO, Google Scholar, article reference lists and personal paper collections of the authors were searched for studies describing rates of fatal and non-fatal self-harm amongst people who presented to health care services for deliberate self-harm. Heterogeneity in pooled estimates of repeat self-harm incidence was investigated using stratified meta-analysis and meta-regression. The search identified 177 relevant papers. The risk of suicide in the 12 months after an index attempt was 1.6% (CI 1.2–2.4) and 3.9% (CI 3.2–4.8) after 5 years. The estimated 1 year rate of non-fatal repeat self-harm was 16.3% (CI 15.1–17.7). This proportion was considerably lower in Asian countries (10.0%, CI 7.3–13.6%) and varies between studies identifying repeat episodes using hospital admission data (13.7%, CI 12.3–15.3) and studies using patient report (21.9%, CI 14.3–32.2). There was no evidence that the incidence of repeat self-harm was lower in more recent (post 2000) studies compared to those from the 1980s and 1990s. Conclusions One in 25 patients presenting to hospital for self-harm will kill themselves in the next 5 years. The incidence of repeat self-harm and suicide in this population has not changed in over 10 years. Different methods of identifying repeat episodes of self-harm produce varying estimates of incidence and this heterogeneity should be considered when evaluating interventions aimed at reducing non-fatal repeat self-harm.

Long term effect of reduced pack sizes of paracetamol on poisoning deaths and liver transplant activity in England and Wales: Interrupted time series analyses

Objective To assess the long term effect of United Kingdom legislation introduced in September 1998 to restrict pack sizes of paracetamol on deaths from paracetamol poisoning and liver unit activity. Design Interrupted time series analyses to assess mean quarterly changes from October 1998 to the end of 2009 relative to projected deaths without the legislation based on pre-legislation trends. Setting Mortality (1993-2009) and liver unit activity (1995-2009) in England and Wales, using information from the Office for National Statistics and NHS Blood and Transplant, respectively. Participants Residents of England and Wales. Main outcome measures Suicide, deaths of undetermined intent, and accidental poisoning deaths involving single drug ingestion of paracetamol and paracetamol compounds in people aged 10 years and over, and liver unit registrations and transplantations for paracetamol induced hepatotoxicity. Results Compared with the pre-legislation level, following the legislation there was an estimated average reduction of 17 (95% confidence interval −25 to −9) deaths per quarter in England and Wales involving paracetamol alone (with or without alcohol) that received suicide or undetermined verdicts. This decrease represented a 43% reduction or an estimated 765 fewer deaths over the 11¼ years after the legislation. A similar effect was found when accidental poisoning deaths were included, and when a conservative method of analysis was used. This decrease was largely unaltered after controlling for a non-significant reduction in deaths involving other methods of poisoning and also suicides by all methods. There was a 61% reduction in registrations for liver transplantation for paracetamol induced hepatotoxicity (−11 (−20 to −1) registrations per quarter). But no reduction was seen in actual transplantations (−3 (−12 to 6)), nor in registrations after a conservative method of analysis was used. Conclusions UK legislation to reduce pack sizes of paracetamol was followed by significant reductions in deaths due to paracetamol overdose, with some indication of fewer registrations for transplantation at liver units during the 11 years after the legislation. The continuing toll of deaths suggests, however, that further preventive measures should be sought.

The Effect of the School Environment on the Emotional Health of Adolescents: A Systematic Review

BACKGROUND AND OBJECTIVES: The evidence base for the importance of the school environment for adolescent emotional health has never been systematically reviewed. We aimed to synthesize the evidence for the effect on adolescent emotional health of (1) interventions targeting the school environment and (2) the school environment in cohort studies. METHODS: Searches of Medline, Embase, PsychINFO, CINAHL, ERIC, the Social Citation Index, and the gray literature were conducted. Criteria for inclusion were (1) cohort or controlled trial designs, (2) participants aged 11 to 18 years, (3) emotional health outcomes, and (4) school environment exposure or intervention. Relevant studies were retrieved and data extracted by 2 independent reviewers. RESULTS: Nine papers reporting 5 controlled trials were reviewed, along with 30 cohort papers reporting 23 studies. Two nonrandomized trials found some evidence that a supportive school environment improved student emotional health, but 3 randomized controlled trials did not. Six (20%) cohort papers examined school-level factors but found no effect. There was some evidence that individual perceptions of school connectedness and teacher support predict future emotional health. Multilevel studies showed school effects were smaller than individual-level effects. Methodological shortcomings were common. CONCLUSIONS: There is limited evidence that the school environment has a major influence on adolescent mental health, although student perceptions of teacher support and school connectedness are associated with better emotional health. More studies measuring school-level factors are needed. Randomized controlled trials evaluating 1 or 2 environmental components may have more success in establishing effective and feasible interventions compared with complex whole-school programs.

Suicide by jumping

This review summarizes the published literature on suicide by jumping, in particular focusing on the social and psychological characteristics of people who have chosen this method of suicide, and the opportunities for prevention. Suicide by jumping accounts for 5% of suicides in England and Wales, and there are marked variations in the use of this method world‐wide. A number of locations have gained notoriety as popular places from which to jump. Such sites include The Golden Gate Bridge and Niagara Falls in the USA, and Beachy Head and the Clifton Suspension Bridge in the UK. There is no consistent evidence that those who commit suicide by jumping differ sociodemographically or in their psychopathology from those who use other methods of suicide, although this method is more often used for in‐patient suicides, possibly due to lack of access to other means. Survivors of suicidal jumps experience higher subsequent rates of suicide and mental ill health, but the majority do not go on to kill themselves, suggesting that preventive efforts may be worthwhile. This view is supported by other evidence that restricting access to the means of suicide may prevent some would‐be suicides. Such measures may also reduce the emotional trauma suffered by those who witness these acts. Health authorities and coroners should consider reviewing local patterns of suicide by jumping, and if necessary institute preventive measures.

Investigating whether adverse prenatal and perinatal events are associated with non-clinical psychotic symptoms at age 12 years in the ALSPAC birth cohort

BACKGROUND Non-clinical psychosis-like symptoms (PLIKS) occur in about 15% of the population. It is not clear whether adverse events during early development alter the risk of developing PLIKS. We aimed to examine whether maternal infection, diabetes or pre-eclampsia during pregnancy, gestational age, perinatal cardiopulmonary resuscitation or 5-min Apgar score were associated with development of psychotic symptoms during early adolescence. METHOD A longitudinal study of 6356 12-year-old adolescents who completed a semi-structured interview for psychotic symptoms in the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. Prenatal and perinatal data were obtained from obstetric records and maternal questionnaires completed during pregnancy. RESULTS The presence of definite psychotic symptoms was associated with maternal infection during pregnancy [adjusted odds ratio (OR) 1.44, 95% confidence interval (CI) 1.11-1.86, p=0.006], maternal diabetes (adjusted OR 3.43, 95% CI 1.14-10.36, p=0.029), need for resuscitation (adjusted OR 1.50, 95% CI 0.97-2.31, p=0.065) and 5-min Apgar score (adjusted OR per unit decrease 1.30, 95% CI 1.12-1.50, p<0.001). None of these associations were mediated by childhood IQ score. Most associations persisted, but were less strong, when including suspected symptoms as part of the outcome. There was no association between PLIKS and gestational age or pre-eclampsia. CONCLUSIONS Adverse events during early development may lead to an increased risk of developing PLIKS. Although the status of PLIKS in relation to clinical disorders such as schizophrenia is not clear, the similarity between these results and findings reported for schizophrenia indicates that future studies of PLIKS may help us to understand how psychotic experiences and clinical disorders develop throughout the life-course.

Smoking cessation treatment and risk of depression, suicide, and self harm in the Clinical Practice Research Datalink: prospective cohort study

Objective To compare the risk of suicide, self harm, and depression in patients prescribed varenicline or bupropion with those prescribed nicotine replacement therapy. Design Prospective cohort study within the Clinical Practice Research Datalink. Setting 349 general practices in England. Participants 119 546 men and women aged 18 years and over who used a smoking cessation product between 1 September 2006 and 31 October 2011. There were 81 545 users of nicotine replacement products (68.2% of all users of smoking cessation medicines), 6741 bupropion (5.6%), and 31 260 varenicline (26.2%) users. Main outcome measures Outcomes were treated depression and fatal and non-fatal self harm within three months of the first smoking cessation prescription, determined from linkage with mortality data from the Office for National Statistics (for suicide) and Hospital Episode Statistics data (for hospital admissions relating to non-fatal self harm). Hazard ratios or risk differences were estimated using Cox multivariable regression models, propensity score matching, and instrumental variable analysis using physicians’ prescribing preferences as an instrument. Sensitivity analyses were performed for outcomes at six and nine months. Results We detected 92 cases of fatal and non-fatal self harm (326.5 events per 100 000 person years) and 1094 primary care records of treated depression (6963.3 per 100 000 person years). Cox regression analyses showed no evidence that patients prescribed varenicline had higher risks of fatal or non-fatal self harm (hazard ratio 0.88, 95% confidence interval 0.52 to 1.49) or treated depression (0.75, 0.65 to 0.87) compared with those prescribed nicotine replacement therapy. There was no evidence that patients prescribed bupropion had a higher risk of fatal or non-fatal self harm (0.83, 0.30 to 2.31) or of treated depression (0.63, 0.46 to 0.87) compared with patients prescribed nicotine replacement therapy. Similar findings were obtained using propensity score methods and instrumental variable analyses. Conclusions There is no evidence of an increased risk of suicidal behaviour in patients prescribed varenicline or bupropion compared with those prescribed nicotine replacement therapy. These findings should be reassuring for users and prescribers of smoking cessation medicines.

Hospital admissions for self harm after discharge from psychiatric inpatient care: cohort study

Objective To determine the risk of non-fatal self harm in the 12 months after discharge from psychiatric inpatient care. Design Cohort study based on national hospital episode statistics. Setting England. Population Patients aged 16-64 years discharged from psychiatric inpatient care between 1 April 2004 and 31 March 2005 and followed up for one year. Results 75 401 people were discharged from psychiatric inpatient care over the study period, 4935 (6.5%) of whom were admitted at least once for self harm in the following 12 months. Risk of self harm was greatest in the four weeks after discharge; one third (32%, n=1578) of admissions for self harm occurred in this period. The strongest risk factor for self harm after discharge was admission for self harm in the previous 12 months (hazard ratio 4.9, 95% confidence interval 4.6 to 5.2). The risk of self harm was also higher in females, younger people, those with diagnoses of depression, personality disorders, and substance misuse, and those with short lengths of stay. Conclusion More than 6% of patients discharged from psychiatric inpatient care are readmitted for an episode of self harm within 12 months, with one third of these episodes occurring in the month after discharge. Self harm after discharge from hospital shares many of the features of suicide after discharge. Interventions should be developed to reduce risk in this period.