Jon Shaw

Suicide in recently discharged psychiatric patients: A case-control study

BACKGROUND Few controlled studies have specifically investigated aspects of mental health care in relation to suicide risk among recently discharged psychiatric patients. We aimed to identify risk factors, including variation in healthcare received, for suicide within 3 months of discharge. METHOD We conducted a national population-based case-control study of 238 psychiatric patients dying by suicide within 3 months of hospital discharge, matched on date of discharge to 238 living controls. RESULTS Forty-three per cent of suicides occurred within a month of discharge, 47% of whom died before their first follow-up appointment. The first week and the first day after discharge were particular high-risk periods. Risk factors for suicide included a history of self-harm, a primary diagnosis of affective disorder, recent last contact with services and expressing clinical symptoms at last contact with staff. Suicide cases were more likely to have initiated their own discharge and to have missed their last appointment with services. Patients who were detained for compulsory treatment at last admission, or who were subject to enhanced levels of aftercare, were less likely to die by suicide. CONCLUSIONS The weeks after discharge from psychiatric care represent a critical period for suicide risk. Measures that could reduce risk include intensive and early community follow-up. Assessment of risk should include established risk factors as well as current mental state and there should be clear follow-up procedures for those who have self-discharged. Recent detention under the Mental Health Act and current use of enhanced levels of aftercare may be protective.

Suicide in schizophrenia: findings from a national clinical survey.

Background. A reduction in suicide among individuals with mental illness is an international public-health priority. Approximately 10% of patients with schizophrenia will die by suicide. Objective. The goal of this study was to describe social and clinical characteristics of people with schizophrenia who completed suicide, including aspects of the clinical care they received. Method. A national clinical survey was conducted based on a 4-year (1996-2000) sample of people in England and Wales who had died by suicide and had been in contact with mental health services in the previous 12 months. Results. Of 20,927 individuals who committed suicide, 5,099 (24%) were known to have been in contact with mental health services in the year prior to death. Completed questionnaires were returned on 4,859 cases of suicide. Of these, 960 (20%) were diagnosed with schizophrenia. These suicides were characterized by more violent modes of death, with over a quarter (27%) jumping from a height or in front of a moving vehicle compared to 10% of the remaining sample. They were more likely than the other individuals in the sample to be young, male, unmarried, and from an ethnic minority with high rates of unemployment. Rates of previous violence and drug abuse were high and they were proportionally more likely to be inpatients at the time of death and to have been noncompliant with medication. Patients with schizophrenia and comorbid substance abuse showed particularly complex social and clinical morbidity. Conclusions. Measures that may prevent suicide among patients with schizophrenia include improved ward safety, closer supervision in both inpatient and community settings, particularly for those with poor medication compliance, and effective treatment of substance abuse.

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.

Suicide in recently released prisoners: a case-control study

BACKGROUND Recently released prisoners are at markedly higher risk of suicide than the general population. The aim of this study was to identify key risk factors for suicide by offenders released from prisons in England and Wales. METHOD All suicides committed by offenders within 12 months of their release from prison in England and Wales, between 2000 and 2002, were identified. One control matched on gender and date of release from prison was recruited for each case. Univariate and multivariate logistic regression modelling identified key independent risk factors for suicide. RESULTS Of 256 920 released prisoners, 384 suicides occurred within a year of release. Factors significantly associated with post-release suicide were increasing age over 25 years, released from a local prison, a history of alcohol misuse or self-harm, a psychiatric diagnosis, and requiring Community Mental Health Services (CMHS) follow-up after release from prison. Non-white ethnicity and a history of previous imprisonment were protective factors. CONCLUSIONS There is a need to improve the continuity of care for people who are released from prison and for community health, offender and social care agencies to coordinate care for these vulnerable individuals.

Characteristics of and trends in subgroups of prisoner suicides in England and Wales

BACKGROUND The suicide rate is higher in prisoners compared with the general population. The aim was to describe the characteristics of and longitudinal trends in prisoner suicides in England and Wales. METHOD A case series was ascertained from the Safer Custody and Offender Policy Group at the Ministry of Justice and included a 9-year (1999-2007) national census of prisoner suicides. Questionnaires were completed by prison staff on sociodemographic, custodial, clinical and service-level characteristics of the suicides. RESULTS There was a fall in the number of prison suicides and a decline in the proportion of young prisoner (18-20 years) suicides over time. Females were over-represented. Upward trends were found in prisoners with a history of violence and with previous mental health service contact. A downward trend was found in those with a primary psychiatric diagnosis of drug dependence. Drug dependence was found to be significant in explaining suicides within the first week of custody. CONCLUSIONS The findings provide an important insight to aid a target set in the National Suicide Prevention Strategy in England to reduce suicides in the prisoner population by 20% and highlight an important area for policy development in mental health services. Examining trends identified subgroups that may require improved mental healthcare and recognized those that appeared to be having their treatment needs more adequately met. Evidence suggests that targeted suicide prevention strategies for subgroups of prisoners are required.

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.

Suicide pacts in the mentally ill: A national clinical survey

There have been no detailed descriptions of psychiatric patients who have died by suicide pact. We examined the social and clinical characteristics of pact cases in England and Wales using a national clinical survey sample of people who died by suicide pact and who had been in recent (<12 months) contact with mental health services. Over the study period (1996-2005), there were 278 cases of suicide who had died in a pact, 77 (28%) of whom had been in recent service contact. The most common cause of death overall was by carbon monoxide poisoning, but those in contact with services were more likely to use more violent methods compared with other pact victims. Nearly half (47%) had affective disorder and 68% had previously self-harmed. Over a quarter (29%) had died within 3 months of discharge from psychiatric care and 36% had missed their last service appointment. Pact cases were more likely than solitary suicide cases to have experienced recent adverse life events, typically family problems. Measures that may prevent suicide pacts in the mentally ill include the effective treatment of depression and closer supervision in both in-patient and community settings. Awareness of the family environment may contribute to reduced risk.