Improving mental health pathways and care for adolescents in transition to adult services (IMPACT): a retrospective case note review of social and clinical determinants of transition.

BACKGROUND: Poor transitions to adult care from child and adolescent mental health services may increase the risk of disengagement and long-term negative outcomes. However, studies of transitions in mental health care are commonly difficult to administer and little is known about the determinants of successful transition. The persistence of health inequalities related to access, care, and outcome is now well accepted including the inverse care law which suggests that those most in need of services may be the least likely to obtain them. We sought to examine the pathways and determinants of transition, including the role of social class. METHOD: A retrospective systematic examination of electronic records and case notes of young people eligible to transition to adult care over a 4-year period across five Health and Social Care NHS Trusts in Northern Ireland. RESULTS: We identified 373 service users eligible for transition. While a high proportion of eligible patients made the transition to adult services, very few received an optimal transition process and many dropped out of services or subsequently disengaged. Clinical factors, rather than social class, appear to be more influential in the transition pathway. However, those not in employment, education or training (NEET) were more likely (OR 3.04: 95% CI 1.34, 6.91) to have been referred to Adult Mental Health Services (AMHS), as were those with a risk assessment or diagnosis (OR 4.89: 2.45, 9.80 and OR 3.36: 1.78, 6.34), respectively. CONCLUSIONS: Despite the importance of a smoother transition to adult services, surprisingly, few patients experience this. There is a need for stronger standardised policies and guidelines to ensure optimal transitional care to AMHS. The barriers between different arms of psychiatry appear to persist. Joint working and shared arrangements between child and adolescent and adult mental health services should be fostered.

The failure of suicide prevention in primary care: family and GP perspectives - a qualitative study.

BACKGROUND: Although Primary care is crucial for suicide prevention, clinicians tend to report completed suicides in their care as non-preventable. We aimed to examine systemic inadequacies in suicide prevention from the perspectives of bereaved family members and GPs. METHODS: Qualitative study of 72 relatives or close friends bereaved by suicide and 19 General Practitioners who have experienced the suicide of patients. RESULTS: Relatives highlight failures in detecting symptoms and behavioral changes and the inability of GPs to understand the needs of patients and their social contexts. A perceived overreliance on anti-depressant treatment is a major source of criticism by family members. GPs tend to lack confidence in the recognition and management of suicidal patients, and report structural inadequacies in service provision. CONCLUSIONS: Mental health and primary care services must find innovative and ethical ways to involve families in the decision-making process for patients at risk of suicide.

Substance misuse in life and death in a 2-year cohort of suicides.

BACKGROUND: Although substance misuse is a key risk factor in suicide, relatively little is known about the relationship between lifetime misuse and misuse at the time of suicide. AIMS: To examine the relationship between substance misuse and subsequent suicide. METHOD: Linkage of coroners' reports to primary care records for 403 suicides occurring over 2 years. RESULTS: With alcohol misuse, 67% of the cohort had previously sought help for alcohol problems and 39% were intoxicated at the time of suicide. Regarding misuse of other substances, 54% of the cohort was tested. Almost one in four (38%) tested positive, defined as an excess of drugs over the prescribed therapeutic dosage and/or detection of illicit substances. Those tested were more likely to be young and have a history of drug misuse. CONCLUSIONS: A deeper understanding of the relationship between substance misuse and suicide could contribute to prevention initiatives. Furthermore, standardised toxicology screening processes would avoid diminishing the importance of psychosocial factors involved in suicide as a 'cause of death'.

Patterns and predictors of help-seeking contacts with health services and general practitioner detection of suicidality prior to suicide: a cohort analysis of suicides occurring over a two-year period.

BACKGROUND: Contact with primary care and psychiatric services prior to suicide may be considerable, presenting opportunities for intervention. However, there is scant knowledge on the frequency, nature and determinants of contact. METHOD: Retrospective cohort study-an analysis of deaths recorded as suicide by the Northern Ireland Coroner's Office linked with data from General Practice patient records over a 2 year period RESULTS: Eighty-seven per cent of suicides were in contact with General Practice services in the 12 months before suicide. The frequency of contact with services was considerable, particularly among patients with a common mental disorder or substance misuse problems. A diagnosis of psychiatric problems was absent in 40% of suicides. Excluding suicide attempts, the main predictors of a noted general practitioner concern for patient suicidality are male gender, frequency of consultations, diagnosis of mental illness and substance misuse. CONCLUSIONS: Despite widespread and frequent contact, a substantial proportion of suicidal people were undiagnosed and untreated for mental health problems. General Practitioner alertness to suicidality may be too narrowly focused.

An exploration of integrated data on the social dynamics of suicide among women.

The gender-based nature of suicide-related behaviour is largely accepted. However, studies that report exclusively on female suicides are rare. Here we demonstrate how female suicide has effectively been 'othered' and appears incidental in studies which compare female and male behaviour. We highlight how recent studies of suicide have tended to be dominated by male-only approaches, which increasingly link issues of masculinity with male death by suicide. Drawing on data collected from the general practitioner and coroner's office, we then apply the sociological autopsy approach to a cohort of 78 deaths recorded as suicides in the UK between 2007 and 2009. By focusing on females in isolation from males, we demonstrate that, as in male-only suicide studies, it is similarly possible to draw out issues associated with the feminine identity, which can be linked to death by suicide. We find that bereavement, sexual violence and motherhood could all be linked to the lives and help-seeking of the females who died. In closing, we suggest that a reorientation towards sociological analytic approaches of female suicide may help to produce further reductions in the rate of female death by suicide. A Virtual Abstract of this paper can be found at: https://www.youtube.com/watch?v=a0w9KKMFdIQ.

Setting the bar: athletes and vulnerability to mental illness.

Whereas physical sport activity is generally considered a health benefit, extreme exercise may be harmful. Of particular concern in this regard is the considerable variation between doctors in the primary care setting and those working within the sports setting around the diagnosis and treatment of athletes presenting with similar symptoms. Known risk factors for athletes are herein presented to raise awareness of the negative side of sport and to bring attention to the psychological outcomes and needs of athletes. The need for research into the incidence and aetiology of mental illness within elite level sport is also raised.

When health services are powerless to prevent suicide: results from a linkage study of suicide among men with no service contact in the year prior to death.

AIMS: To investigate cases of suicide in which there was no healthcare contact, by looking at history of help-seeking and evidence of previous mental health vulnerability. To identify any life events associated with suicide for which individuals did not seek help. BACKGROUND: Previous research has suggested that non-consultation is the main barrier to suicide prevention among men. Estimates suggest approximately 22% of men who die by suicide have not consulted their GP in the year before their death. Little is known about the lifetime pattern of engagement with services among these individuals and whether or not this may influence their help-seeking behaviour before death. METHODS: Coroner records of suicide deaths in Northern Ireland over 2 years were linked to general practice (GP) records. This identified 63 individuals who had not attended health services in the 12 months before death. Coroner's data were used to categorise life events associated with the male deaths. Lifetime mental health help-seeking at the GP was assessed. FINDINGS: The vast majority of individuals who did not seek help were males (n=60, 15% of all suicide deaths). Lack of consultation in the year before suicide was consistent with behaviour over the lifespan; over two-thirds had no previous consultations for mental health. In Coroner's records, suicides with no prior consultation were primarily linked to relationship breakdown and job loss. These findings highlight the limitations of primary care in suicide prevention as most had never attended GP for mental health issues and there was a high rate of supported consultation among those who had previously sought help. Public health campaigns that promote service use among vulnerable groups at times of crisis might usefully be targeted at those likely to be experiencing financial and relationship issues.

Patterns of presentation for attempted suicide: analysis of a cohort of individuals who subsequently died by suicide.

All suicides and related prior attempts occurring in Northern Ireland over two years were analyzed, focusing on number and timing of attempts, method, and mental health diagnoses. Cases were derived from coroner's records, with 90% subsequently linked to associated general practice records. Of those included, 45% recorded at least one prior attempt (with 59% switching from less to more lethal methods between attempt and suicide). Compared with those recording one attempt, those with 2+ attempts were more likely to have used less lethal methods at the suicide (OR = 2.77: 95% CI = 1.06, 7.23); and those using less lethal methods at the attempts were more likely to persist with these into the suicide (OR = 3.21: 0.79, 13.07). Finally, those with preexisting mental problems were more likely to use less lethal methods in the suicide: severe mental illness (OR = 7.88: 1.58, 39.43); common mental problems (OR = 3.68: 0.83, 16.30); and alcohol/drugs related (OR = 2.02: 0.41, 9.95). This analysis uses readily available data to highlight the persisting use of less lethal methods by visible and vulnerable attempters who eventually complete their suicide. Further analysis of such conditions could allow more effective prevention strategies to be developed.