David While

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.

A longitudinal study of teacher change: what makes professional development effective?

This preliminary analysis is part of the baseline phase of a longitudinal study designed to investigate the professional development of primary and secondary teachers across England. The study addresses four key research areas. The prevailing models of professional development for teachers in England are identified in this baseline phase and the scene is set for the remaining areas of investigation to be addressed (annual data collection sweeps will continue).

Suicide after leaving the UK armed forces--a cohort study.

Background Few studies have examined suicide risk in individuals once they have left the military. We aimed to investigate the rate, timing, and risk factors for suicide in all those who had left the UK Armed Forces (1996–2005). Methods and Findings We carried out a cohort study of ex-Armed Forces personnel by linking national databases of discharged personnel and suicide deaths (which included deaths receiving either a suicide or undetermined verdict). Comparisons were made with both general and serving populations. During the study period 233,803 individuals left the Armed Forces and 224 died by suicide. Although the overall rate of suicide was not greater than that in the general population, the risk of suicide in men aged 24 y and younger who had left the Armed Forces was approximately two to three times higher than the risk for the same age groups in the general and serving populations (age-specific rate ratios ranging from 170 to 290). The risk of suicide for men aged 30–49 y was lower than that in the general population. The risk was persistent but may have been at its highest in the first 2 y following discharge. The risk of suicide was greatest in males, those who had served in the Army, those with a short length of service, and those of lower rank. The rate of contact with specialist mental health was lowest in the age groups at greatest risk of suicide (14% for those aged under 20 y, 20% for those aged 20–24 y). Conclusions Young men who leave the UK Armed Forces were at increased risk of suicide. This may reflect preservice vulnerabilities rather than factors related to service experiences or discharge. Preventive strategies might include practical and psychological preparation for discharge and encouraging appropriate help-seeking behaviour once individuals have left the services.

Suicide in juveniles and adolescents in the United Kingdom

BACKGROUND Suicide is a leading cause of death among youths. Comparatively few studies have studied recent trends over time, or examined rates and characteristics of service contact in well-defined national samples. METHODS Data on general population suicides and mid-year population estimates were used to calculate suicide rates (per 100,000/year) among youths aged 10-19 years in the United Kingdom. We then determined the proportion of youths who had been in mental health service contact in the year prior to death. Social and clinical data were collected via questionnaires sent to clinicians who had provided care. RESULTS The general population rate of suicide was higher in males than females, and was higher in 15-19-year-olds compared to 10-14-year-olds. Suicide rates for 10-19-year-olds declined by 28% between 1 January 1997 and 31 December 2003 (compared with an 8% reduction in those aged >19 years); the fall was particularly marked for males. Mental health service contact was low at 14% (compared with 26% for adults), especially for males (12%). Youths in mental health contact were characterised by: diagnosis of affective disorder, mental illness history, residential instability, self-harm, and substance misuse. Over half of youths were living with parents and one-fifth were in full-time education. CONCLUSIONS The suicide rate for 10-19-year-olds in the UK appeared to fall between 1997 and 2003. Further monitoring of suicide rates is needed to determine whether this trend has continued for the most recent years (e.g., 2004-7). The fall in rates may have been related to socio-economic or clinical factors. The rate of contact with services was low compared to adults, particularly in males. This is concerning because young males have the highest suicide rate in the UK. Suicide prevention in young people is likely to require a multi-agency approach.

Emergency department contact prior to suicide in mental health patients

Objectives To describe attendance at emergency departments (EDs) in the year prior to suicide for a sample of mental health patients. To examine the characteristics of those who attended (particularly those who attended frequently) prior to suicide. Design Case review of ED records for 286 individuals who died within 12 months of mental health contact in North West England (2003–2005). Method Cases identified through the National Confidential Inquiry into Suicide were checked against regional EDs to establish attendance in the year prior to death. Records were examined to establish the number of attendances, reason for the final, non-fatal attendance, treatment offered and outcome. Results One hundred and twenty-four (43%) individuals had attended the ED at least once in the year prior to their death, and of these, 35 (28%) had attended the ED on more than three occasions. These frequent attenders died by suicide significantly sooner after their final, non-fatal attendance than other attenders. A clinical history of alcohol misuse was also associated with early death following ED attendance. Conclusions Over 40% of our clinical sample attended an ED in the year prior to death, and some individuals attended particularly frequently. EDs may therefore represent an important additional setting for suicide prevention in mental health patients. The majority of attendances prior to suicide were for self-harm or to request psychiatric help. Clinicians should be alert to the risk associated with such presentations and to the possible association between frequent attendance and suicide.

Children's Adjustment During the First Year of a Parent's Cancer Diagnosis

Abstract This study investigated the psychosocial adjustment of 80 school-age children (aged 8 to 16 years) during the first year of a parents cancer diagnosis. Based on a cognitive model of stress and coping, the aims were to consider within-group variability in childrens responses and to identify the strongest factors associated with good or poor adjustment. Mixed methods of data collection (standardized measures and semistructured interviews) were used to facilitate a more sensitive and reliable assessment of the childrens experiences. The study was innovative in triangulating the sources of outcome measures and thus obtained self-reported data as well as assessments from parents and teachers. After multivariate analysis, the two main risk factors shown to be independently associated with poor adjustment in children were low self-esteem (p = .002) and poor adjustment in the parent with cancer (p = .01).

Primary care contact prior to suicide in individuals with mental illness

BACKGROUND Previous studies have reported differing rates of consultation with GPs prior to suicide. Patients with a psychiatric history have higher rates of consultation and consult closer to the time of their death. AIM To investigate the frequency and nature of general practice consultations in the year before suicide for patients in current, or recent, contact with secondary mental health services. DESIGN OF STUDY Retrospective case-note study and semi-structured interviews. SETTING General practices in the northwest of England. METHOD General practice data were obtained by a retrospective review of medical records (n = 247) and semi-structured interviews with GPs (n = 159). RESULTS GP records were reviewed in 247 of the 286 cases (86%). Overall, 91% of individuals (n = 224) consulted their GP on at least one occasion in the year before death. The median number of consultations was 7 (interquartile range = 3-10). Interviews were carried out with GPs with regard to 159 patients. GPs reported concerns about their patients safety in 43 (27%) cases, but only 16% of them thought that the suicide could have been prevented. Agreement between GPs and mental health teams regarding risk of suicide was poor. Both sets of clinicians rated moderate to high levels of risk in only 3% of cases for whom information was available (n = 139) (overall kappa = 0.024). CONCLUSION Consultation prior to suicide is common but suicide prevention in primary care is challenging. Possible strategies might include examining the potential benefits of risk assessment and collaborative working between primary and secondary care.

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.

Smoking prevalence among 16-19-year-olds related to staff and student smoking policies in sixth forms and further education

The purpose of this study was to identify the policies, if any, regulating where and when smoking was allowed in educational establishments for students aged 16 and over, and to relate them to smoking prevalence. The methods used were postal questionnaires to all directors of local education authorities in England and Wales and to a sample of school and college principals in 1990. Self-administered questionnaires were used for the sample of students, supervised by staff. The results showed that 37 per cent of the responding local directors of education had a written policy on smoking for the schools and colleges in their area. Responses from principals showed that 83 per cent of colleges and 14 per cent of schools officially allowed students aged 16 and over to smoke. Eighty-three per cent of colleges and 97 per cent of schools allowed staff to smoke, but not usually in front of students. Policy and prevalence were strongly related in colleges, but not in the schools. The possible reasons for and implications of these findings are discussed. Overall, smoking students smoked fewer cigarettes (7 per week during attendance hours and 18 outside) in establishments where they were not allowed to smoke, as against 17 during attendance hours and 28 outside when the policy allowed smoking. The policy was still significantly related to lower smoking prevalence in colleges when other factors were taken into account. The response rates were low and the risk of bias is high, however; the findings suggest the need to investigate the topic further.

Mental illness, gender and homicide: A population-based descriptive study

In England and Wales, a lifetime history of mental disorder is recorded in almost a third of homicides but mental illness as a defence in homicide cases has recently come under review. In this study, we aimed to compare the social, criminological and clinical characteristics of women and men convicted of homicide and secondly, to understand how pathways through the judicial system differ by gender of the perpetrator, characteristics of the offence and mental illness. A cross sectional study of 4572 convicted homicide perpetrators in England and Wales 1997-2004 was performed. Significantly more women who had committed homicide had a lifetime history of mental illness and were more likely to be mentally ill at the time of offence compared to men. Women more often received non-custodial sentences, whether or not they had mental illness. If the victim were a child or other relative, the courts were more lenient with women. Gender and the presence of mental illness both influence the characteristics of homicide and outcome of the legal process in the UK. Our findings suggest that all perpetrators of homicide should have a psychiatric assessment pre-trial. Psychiatrists need to rate risk objectively in a gender blind way when providing psychiatric reports to be used as evidence in court.