Jenny Shaw

Suicide within 12 months of contact with mental health services: national clinical survey

Objective: To describe the clinical circumstances in which psychiatric patients commit suicide. Design: National clinical survey. Setting: England and Wales. Subjects: A two year sample of people who had committed suicide, in particular those who had been in contact with mental health services in the 12 months before death. Main outcome measures: Proportion of suicides in people who had had recent contact with mental health services; proportion of suicides in inpatients; proportion of people committing suicide and timing of suicide within three months of hospital discharge; proportion receiving high priority under the care programme approach; proportion who were recently non-compliant and not attending. Results: 10 040 suicides were notified to the study between April 1996 and March 1998, of whom 2370 (24%; 95% confidence interval 23% to 24%) had had contact with mental health services in the year before death. Data were obtained on 2177, a response rate of 92%. In general these subjects had broad social and clinical needs. Alcohol and drug misuse were common. 358 (16%; 15% to 18%) were psychiatric inpatients at the time of death, 21% (17% to 25%) of whom were under special observation. Difficulties in observing patients because of ward design and nursing shortages were both reported in around a quarter of inpatient suicides. 519 (24%; 22% to 26%) suicides occurred within three months of hospital discharge, the highest number occurring in the first week after discharge. 914 (43%; 40% to 44%) were in the highest priority category for community care. 488 (26% excluding people whose compliance was unknown; 24% to 28%) were non-compliant with drug treatment while 486 (28%; 26% to 30%) community patients had lost contact with services. Most people who committed suicide were thought to have been at no or low immediate risk at the final service contact. Mental health teams believed suicide could have been prevented in 423 (22%; 20% to 24%) cases. Conclusions: Several suicide prevention measures in mental health services are implied by these findings, including measures to improve compliance and prevent loss of contact with services. Inpatient facilities should remove structural difficulties in observing patients and fixtures that can be used in hanging. Prevention of suicide after discharge may require earlier follow up in the community. Better suicide prevention in psychiatric patients is likely to need measures to improve the safety of mental health services as a whole, rather than specific measures for people known to be at high risk.

Suicide in recently released prisoners: a population-based cohort study.

BACKGROUND Several studies have been undertaken on suicide in custody, but few on suicide after the release from prison. We undertook a population-based cohort study to investigate suicide rates in recently released prisoners in England and Wales. METHODS We used the database of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness for England and Wales to identify all individuals who died by suicide or who received an open verdict at the coroners inquest between 2000 and 2002. These records were linked to a Home Office register to identify all such deaths in people within 1 year of release from prison in England and Wales. We compared suicide rates per 100,000 person-years in these released prisoners with rates in the general population by using the indirectly age-standardised mortality ratio. FINDINGS We identified 382 suicides occurring in 244 988 individuals within 1 year of release from prison; a suicide rate of 156 per 100 000 person-years. 79 (21%) suicides occurred within the first 28 days after release. In all age groups, suicide rates were higher in recently released prisoners than in the general population. The overall age-standardised mortality ratio for recently released prisoners was 8.3 (95% CI 7.5-9.3) for men and 35.8 (25.4-50.2) for women. INTERPRETATION Recently released prisoners are at a much greater risk of suicide than the general population, especially in the first few weeks after release. The risk of suicide in recently released prisoners is approaching that seen in discharged psychiatric patients. A shared responsibility lies with the prison, probation, health, and social services to develop more collaborative practices in providing services for this high-risk group.

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.

Mental disorder and clinical care in people convicted of homicide: national clinical survey

Abstract Objectives: To estimate the rate of mental disorder in those convicted of homicide and to examine the social and clinical characteristics of those with a history of contact with psychiatric services. Design: National clinical survey. Setting: England and Wales. Subjects: Eighteen month sample of people convicted of homicide. Main outcome measures: Offence related and clinical information collected from psychiatric court reports on people convicted of homicide. Detailed clinical data collected on those with a history of contact with psychiatric services. Results: 718 homicides were reported to the inquiry between April 1996 and November 1997. Of the 500 cases for whom psychiatric reports were retrieved, 220 (44%; 95% confidence interval 40% to 48%) had a lifetime history of mental disorder, while 71 (14%; 11% to 17%) had symptoms of mental illness at the time of the homicide. Of the total sample, 102 (14%; 12% to 17%) were confirmed to have been in contact with mental health services at some time, 58 (8%; 6% to 10%) in the year before the homicide. The commonest diagnosis was personality disorder (20 cases, 22%; 13% to 30%). Alcohol and drug misuse were also common. Only 15 subjects (18%; 10% to 26%) were receiving intensive community care, and 60 (63%; 53% to 73%) were out of contact at the time of the homicide. Conclusions: There are substantial rates of mental disorder in people convicted of homicide. Most do not have severe mental illness or a history of contact with mental health services. Inquiry findings suggest that preventing loss of contact with services and improving the clinical management of patients with both mental illness and substance misuse may reduce risk, but clinical trials are needed to examine the effectiveness of such interventions.

Suicide in current psychiatric in-patients: a case-control study The National Confidential Inquiry into Suicide and Homicide.

BACKGROUND Few controlled studies have investigated factors associated with suicide in current in-patients. We aimed to identify psychosocial, behavioural and clinical risk factors, including variations in care, for in-patient suicide. METHOD We conducted a national population-based case-control study of people who died by suicide between 1 April 1999 and 31 December 2000 while in psychiatric in-patient care in England. Cases were 222 adult mental health in-patients who died by suicide matched on date of death with 222 living controls. RESULTS Nearly a quarter of suicides took place within the first week of admission; most of these died on the ward or after absconding. After the first week, however, most suicides occurred away from the ward, the majority of patients having left the ward with staff agreement. Previous deliberate self-harm, recent adverse life events, symptoms of mental illness at last contact with staff and a co-morbid psychiatric disorder were associated with increased risk for suicide. Being off the ward without staff agreement was a particularly strong predictor. Those patients who were detained for compulsory treatment were less likely to die by suicide. Independent predictors of in-patient suicide were male sex, a primary diagnosis of affective disorder and a history of self-harm. Being unemployed or on long-term sick leave appeared to be independently protective. CONCLUSION Prevention of in-patient suicide should emphasize adequate treatment of affective disorder, vigilance in the first week of admission and regular risk assessments during recovery and prior to granting leave. Use of compulsory treatment may reduce risk.

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.

Homicide due to mental disorder in England and Wales over 50 years

BACKGROUND It has been stated that rates of homicide due to mental disorder are constant over time. AIMS To examine whether there were changes in the rates of homicide due to mental disorder over time, and whether changes in these rates were associated with changes in the rates of other homicides in England and Wales. METHOD Examination of four sets of official homicide statistics from England and Wales from 1946 to 2004. RESULTS The rate of total homicide and the rate of homicide due to mental disorder rose steadily until the mid-1970s. From then there was a reversal in the rate of homicides attributed to mental disorder, which declined to historically low levels, while other homicides continued to rise. CONCLUSIONS The reasons for the rise and fall in homicides attributed to mental disorder are not clear. The earlier increase in such homicides may have been due to the same sociological factors that caused the increase in other homicides over that time. The subsequent decline may have been due to improvements in psychiatric treatments and service organisation. Another possibility is that there has been an informal change to the legal tests for the finding of homicide due to mental disorder.

Prospective cohort study of mental health during imprisonment

BACKGROUND Mental illness is common among prisoners, but little evidence exists regarding changes in symptoms in custody over time. AIMS To investigate the prevalence and predictors of psychiatric symptoms among prisoners during early custody. METHOD In a prospective cohort study, 3079 prisoners were screened for mental illness within 3 days of reception. To establish baseline diagnoses and symptoms, 980 prisoners were interviewed; all remaining in custody were followed up 1 month and 2 months later. RESULTS Symptom prevalence was highest during the first week of custody. Prevalence showed a linear decline among men and convicted prisoners, but not women or remand prisoners. It decreased among prisoners with depression, but not among prisoners with other mental illnesses. CONCLUSIONS Overall, imprisonment did not exacerbate psychiatric symptoms, although differences in group responses were observed. Continued discussion regarding non-custodial alternatives for vulnerable groups and increased support for all during early custody are recommended.

National Study of Suicide in All People With a Criminal Justice History

CONTEXT Previous research has focused on suicide among male prisoners and ex-prisoners, but little is known about risk in the wider offender population. OBJECTIVE To examine suicide risk over 3 decades among all people processed by a national criminal justice system. DESIGN Nested case-control study. SETTING The whole Danish population. PARTICIPANTS Interlinked national registers identified all adult suicides during 1981 to 2006 according to any criminal justice system contact since 1980. Exposure was defined according to history of criminal justice adjudication, up to and including each subjects last judicial verdict before suicide (or date of matching for controls). There were 27 219 suicides and 524 899 controls matched on age, sex, and time, ie, controls were alive when their matched case died. MAIN OUTCOME MEASURE Suicide. RESULTS More than a third of all male cases had a criminal justice history, but relative risk against the general population was higher for women than men. Independent effects linked with criminal justice exposure persisted with confounder adjustment. Suicide risk was markedly elevated with custodial sentencing, but the strongest effects were with sentencing to psychiatric treatment and with charges conditionally withdrawn. Risk was raised even in people with a criminal justice history but without custodial sentences or guilty verdicts. It was especially high with recent or frequent contact and in people charged with violent offenses. CONCLUSIONS We examined a section of society in which major health and social problems frequently coexist including offending, psychopathology, and suicidal behavior. The need for developing more far-reaching national suicide prevention strategies is indicated. In particular, improved mental health service provision is needed for all people in contact with the criminal justice system, including those not found guilty and those not given custodial sentences. Our findings also suggest that public services should be better coordinated to tackle co-occurring health and social problems more effectively.

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.