Nicola Swinson

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.

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.

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.

Suicide amongst psychiatric in-patients who abscond from the ward: a national clinical survey

BackgroundSuicide prevention by mental health services requires an awareness of the antecedents of suicide amongst high risk groups such as psychiatric in-patients. The goal of this study was to describe the social and clinical characteristics of people who had absconded from an in-patient psychiatric ward prior to suicide, including aspects of the clinical care they received.MethodsWe carried out a national clinical survey based on a 10-year (1997-2006) sample of people in England and Wales who had died by suicide. Detailed data were collected on those who had been in contact with mental health services in the year before death.ResultsThere were 1,851 cases of suicide by current psychiatric in-patients, 14% of all patient suicides. 1,292 (70%) occurred off the ward. Four hundred and sixty-nine of these patients died after absconding from the ward, representing 25% of all in-patient suicides and 38% of those that occurred off the ward. Absconding suicides were characterised by being young, unemployed and homeless compared to those who were off the ward with staff agreement. Schizophrenia was the most common diagnosis, and rates of previous violence and substance misuse were high. Absconders were proportionally more likely than in-patients on agreed leave to have been legally detained for treatment, non-compliant with medication, and to have died in the first week of admission. Whilst absconding patients were significantly more likely to have been under a high level of observation, clinicians reported more problems in observation due to either the ward design or other patients on the ward.ConclusionMeasures that may prevent absconding and subsequent suicide amongst in-patients might include tighter control of ward exits, and more intensive observation of patients, particularly in the early days of admission. Improving the ward environment to provide a supportive and less intimidating experience may contribute to reduced risk.

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.

Trends in rates of mental illness in homicide perpetrators

BACKGROUND The rise in homicides by those with serious mental illness is of concern, although this increase may not be continuing. AIMS To examine rates of mental illness among homicide perpetrators. METHOD A national consecutive case series of homicide perpetrators in England and Wales from 1997 to 2006. Rates of mental disorder were based on data from psychiatric reports, contact with psychiatric services, diminished responsibility verdict and hospital disposal. RESULTS Of the 5884 homicides notified to the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness between 1997 and 2006, the number of homicide perpetrators with schizophrenia increased at a rate of 4% per year, those with psychotic symptoms at the time of the offence increased by 6% per year. The number of verdicts of diminished responsibility decreased but no change was found in the number of perpetrators receiving a hospital order disposal. The likeliest explanation for the rise in homicide by people with psychosis is the misuse of drugs and/or alcohol, which our data show increased at a similar magnitude to homicides by those with psychotic symptoms. However, we are unable to demonstrate a causal association. Although the Poisson regression provides evidence of an upward trend in homicide by people with serious mental illness between 1997 and 2006, the number of homicides fell in the final 2 years of data collection, so these findings should be treated with caution. CONCLUSIONS There appears to be a concomitant increase in drug misuse over the period, which may account for this rise in homicide. However, an increase in the number of people in contact with mental health services may suggest that access to mental health services is improving. Previous studies have used court verdicts such as diminished responsibility as a proxy measure of mental disorder. Our data indicate that this does not reflect accurately the prevalence of mental disorder in this population.

Suicide prevention in primary care: General practitioners' views on service availability

BackgroundPrimary care may be a key setting for suicide prevention. However, comparatively little is known about the services available in primary care for suicide prevention. The aims of the current study were to describe services available in general practices for the management of suicidal patients and to examine GPs views on these services. We carried out a questionnaire and interview study in the North West of England. We collected data on GPs views of suicide prevention generally as well as local mental health service provision.FindingsDuring the study period (2003-2005) we used the National Confidential Inquiry Suicide database to identify 286 general practitioners (GPs) who had registered patients who had died by suicide. Data were collected from GPs and practice managers in 167 practices. Responses suggested that there was greater availability of services and training for general mental health issues than for suicide prevention specifically. The three key themes which emerged from GP interviews were: barriers accessing primary or secondary mental health services; obstacles faced when referring a patient to mental health services; managing change within mental health care servicesConclusionsHealth professionals have an important role to play in preventing suicide. However, GPs expressed concerns about the quality of primary care mental health service provision and difficulties with access to secondary mental health services. Addressing these issues could facilitate future suicide prevention in primary care.

Comparison of British National Newspaper Coverage of Homicide Committed by Perpetrators with and Without Mental Illness

Objective: Adverse newspaper reporting of mental illness and in particular, violence committed by a mentally ill person, is thought to contribute to stigma. However, violent events are also considered highly newsworthy by journalists. The aim of this study was to compare the likelihood of newspaper reporting for convicted perpetrators of homicide with and without a history of contact with mental health services. Method: A 12 month (April 2000-March 2001) cohort of 577 homicide perpetrators with and without a history of contact with mental health services in England and Wales was examined. These cases were identified by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. By examining 12 national newspapers, we compared the likelihood of reporting homicide perpetrators with and without mental illness. Results: Under half (228 cases, 40%) of the homicide perpetrators were reported in at least one of the study newspapers. Under a fifth (94 cases, 16%) of perpetrators had a history of contact with mental health services and such previous contact did not increase the likelihood of newspaper reporting (odds ratio 1.0 (0.6–1.6)). Conclusions: Previous contact with mental health services did not influence the newsworthiness of a homicide perpetrator. The stigmatizing effect of reporting homicide by perpetrators with mental illness may relate more to the quality of reporting rather than selective over-reporting.