Tim Amos

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.

Life events preceding suicide by young people

Background Life events are often reported to precede suicide. This paper aims to determine the frequency, timing and type of life events preceding suicide by young people and those with and without a mental illness. Method Informants, usually family members, were interviewed for a sample of young (less than 35 years) suicides. Information was recorded on events occurring in the 6 months before death. Equivalent information was obtained for living controls who had been matched for age and gender and obtained through the general practices of the suicides. Results Suicide was associated with life events in the previous 3 months, and particularly in the previous week. Specifically, interpersonal and forensic (being arrested, charged or sentenced) events distinguished suicides and controls. The number of life events in the different time periods under study did not distinguish suicides with and without severe mental illness, although more suicides without a severe mental illness had a reported life event in the week before their death. Conclusions Adverse life events frequently precede suicide in young people with and without severe mental illness. However, recent life events may have a lesser causal role in those with severe mental illness. Clinical and health promotion measures to improve the way that young people cope with interpersonal problems and other crises may be an important part of any suicide prevention strategy.

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.

REDUCING DURATION OF UNTREATED PSYCHOSIS: CARE PATHWAYS TO EARLY INTERVENTION IN PSYCHOSIS SERVICES

BACKGROUND Interventions to reduce treatment delay in first-episode psychosis have met with mixed results. Systematic reviews highlight the need for greater understanding of delays within the care pathway if successful strategies are to be developed. AIMS To document the care-pathway components of duration of untreated psychosis (DUP) and their link with delays in accessing specialised early intervention services (EIS). To model the likely impact on efforts to reduce DUP of targeted changes in the care pathway. METHOD Data for 343 individuals from the Birmingham, UK, lead site of the National EDEN cohort study were analysed. RESULTS A third of the cohort had a DUP exceeding 6 months. The greatest contribution to DUP for the whole cohort came from delays within mental health services, followed by help-seeking delays. It was found that delay in reaching EIS was strongly correlated with longer DUP. CONCLUSIONS Community education and awareness campaigns to reduce DUP may be constrained by later delays within mental health services, especially access to EIS. Our methodology, based on analysis of care pathways, will have international application when devising strategies to reduce DUP.

Changes in rates of suicide by car exhaust asphyxiation in England and Wales.

BACKGROUND Self-asphyxiation using car exhaust gas is a common method of suicide in England and Wales, particularly in young males. The introduction of catalytic converters has reduced the toxicity of car exhausts. The main aims of the study were: to seek evidence of a fall in car exhaust suicides in the general population and in age and gender groups; to relate any fall to changes in car exhaust systems, particularly since legislation on car exhaust emissions in 1993; and to examine rates of suicide by other methods for evidence of method substitution. METHODS Population study in England and Wales using national suicide statistics for 1987 to 1998. RESULTS There was a fall in suicide by car exhaust asphyxiation in all age and gender groups. This change was most marked after 1993. The overall population suicide rate (all methods) also fell but there was no overall change in suicides by young males or females. In these groups suicide by hanging increased. CONCLUSIONS Legislation on catalytic converters appears to have contributed to a fall in car exhaust suicides. However, the effect on overall suicide rates in young people has been reduced by method substitution.

Psychiatric patients’ views on why their involuntary hospitalisation was right or wrong: a qualitative study

PurposeTo explore involuntary patients’ retrospective views on why their hospitalisation was right or wrong.MethodsInvoluntary patients were recruited from 22 hospitals in England and interviewed in-depth. The study drew on grounded theory and thematic analysis.ResultsMost of the patients felt mentally unwell before admission and out of control during their treatment. Despite these common experiences, three groups of patients with distinct views on their involuntary hospitalisation were identified: those who believed that it was right, those who thought it was wrong and those with ambivalent views. Those with retrospectively positive views believed that hospitalisation ensured that they received treatment, averted further harm and offered them the opportunity to recover in a safe place. They felt that coercion was necessary, as they could not recognise that they needed help when acutely unwell. Those who believed that involuntary admission was wrong thought that their problems could have been managed through less coercive interventions, and experienced hospitalisation as an unjust infringement of their autonomy, posing a permanent threat to their independence. Patients with ambivalent views believed that they needed acute treatment and that hospitalisation averted further harm. Nonetheless, they thought that their problems might have been managed through less coercive community interventions or a shorter voluntary hospitalisation.ConclusionsThe study illustrates why some patients view their involuntary hospitalisation positively, whereas others believe it was wrong. This knowledge could inform the development of interventions to improve patients’ views and treatment experiences.

Views of Young People in Early Intervention Services for First-Episode Psychosis in England

OBJECTIVE This study described the views over time of young people referred to early intervention services (EIS), particularly as they relate to the importance of relationships. METHODS A cohort of people aged 14 to 35 enrolled in a large multisite study of EIS for psychosis in the United Kingdom were recruited for a qualitative, longitudinal study in which they were interviewed within six months of admission to EIS and 12 months later. Transcripts of the interviews were analyzed using Charmazs constructivist grounded-theory methodology. RESULTS A total of 63 individuals were interviewed during the six months after their first service contact, and 36 (57%) were interviewed 12 months later. Service users generally viewed IES key workers as supportive and youth sensitive, but up to one-third felt that the three years of sustained engagement expected was too intensive. Family support was highly valued by service users, and key workers and families worked well together to support the young people as they recovered. A significant minority of service users, however, reported feeling the emergence of a new self-identity, often associated with a sense of loss of the person they had felt themselves to be before becoming ill. CONCLUSIONS EIS for young people should provide not only the right type of engagement but also the right amount, recognize the very important role of families in giving both practical and emotional support and in liaising with key workers, and take into account the relatively rapid change in perceptions of personal identity that accompany illness.

The UK national evaluation of the development and impact of Early Intervention Services (the National EDEN studies): study rationale, design and baseline characteristics

National EDEN aims to evaluate the implementation and impact on key outcomes of somewhat differently configured Early Intervention Services (EIS) across sites in England and to develop a model of variance in patient outcomes that includes key variables of duration of untreated psychosis (DUP), fidelity to the EIS model and service engagement. The cohort is being followed up for two further years as patients are discharged, to observe the stability of change and the impact of the discharge settings.

Mental illness in people who kill strangers: longitudinal study and national clinical survey

Abstract Objectives To establish changes over time in the frequency of homicides committed by strangers, and to describe the personal and clinical characteristics of perpetrators of stranger homicides. Design Longitudinal study and national clinical survey. Participants People convicted of homicide in England and Wales between 1996 and 1999 and whether the victim was known to the perpetrator. Setting England and Wales. Main outcome measure Characteristics of perpetrators of homicides according to whether victims were strangers or not. Results Stranger homicides increased between 1967 and 1997, both in number and as a proportion of all homicides. No increase was found, however, in the number of perpetrators placed under a hospital order after homicide, whether all homicides or stranger homicides only. 358 of 1594 (22%) homicides were stranger homicides. In these cases the perpetrator was more likely to be male and young. The method of killing was more likely to be by hitting, kicking, or pushing (36% (130 of 358) for victims who were strangers to the perpetrator compared with 14% (145 of 1074) for victims who were known). Perpetrators were less likely to have a history of mental disorder (34%, n = 80 ν 50%, n = 142), a history of contact with mental health services (16%, 37 of 234 ν 24%, 200 of 824), and psychiatric symptoms at the time of the offence (6%, n = 14 ν 18%, n = 143). They were more likely to have a history of drug misuse (47%, n = 93 ν 37%, n = 272); alcohol (56%, n = 94 ν 41%, n = 285) or drugs (24% n = 44 ν 12%, n = 86) were more likely to have contributed to the offence. Conclusions Stranger homicides have increased, but the increase is not the result of homicides by mentally ill people and therefore the “care in the community” policy. Stranger homicides are more likely to be related to alcohol or drug misuse by young men.

Pathways to Violent Behavior During First-Episode Psychosis: A Report From the UK National EDEN Study

IMPORTANCE Although many studies have explored the correlates of violence during first-episode psychosis (FEP), most have simply compared violent psychotic individuals with nonviolent psychotic individuals. Accumulating evidence suggests there may be subgroups within psychosis, differing in terms of developmental processes and proximal factors associated with violent behavior. OBJECTIVE To determine whether there are subgroups of psychotic individuals characterized by different developmental trajectories to violent behavior. DESIGN, SETTING, AND PARTICIPANTS The National EDEN (Evaluating the Development and Impact of Early Intervention Services in the West Midlands) Study longitudinal cohort assessed premorbid delinquency (premorbid adjustment adaptation subscale across childhood and adolescence), age at illness onset, duration of untreated psychosis, past drug use, positive symptoms, and violent behavior. Group trajectories of premorbid delinquency were estimated using latent class growth analysis, and associations with violent behavior were quantified. This study included 6 early intervention services in 5 geographical locations across England, with violent behavior information available for 670 first-episode psychosis cases. MAIN OUTCOMES AND MEASURES Violent behavior at 6 or 12 months following early intervention services entry. RESULTS Four groups of premorbid delinquency were identified: stable low, adolescent-onset high to moderate, stable moderate, and stable high. Logistic regression analysis, with stable low delinquency as the reference group, demonstrated that moderate (odds ratio, 1.97; 95% CI, 1.12-3.46) and high (odds ratio, 3.53; 95% CI, 1.85-6.73) premorbid delinquency trajectories increased the risk for violent behavior during FEP. After controlling for confounders, path analysis demonstrated that the increased risk for violence in the moderate delinquency group was indirect (ie, partially mediated by positive symptoms) (probit coefficient [β] = 0.12; P = .002); while stable high delinquency directly increased the risk for violence (β = 0.38; P = .05). CONCLUSIONS AND RELEVANCE There appear to be diverse pathways to violent behavior during FEP. Stable high premorbid delinquency from childhood onwards appears to directly increase the risk for violent behavior, independent of psychosis-related risk factors. In addition to tackling illness-related risks, treatments should directly address antisocial traits as a potent risk for violence during FEP.