Psychiatric in-patient care in England: as safe as it can be? An examination of in-patient suicide between 2009 and 2020.

BACKGROUND: Psychiatric in-patients have a greatly elevated risk of suicide. We aimed to examine trends in in-patient suicide rates and determine if characteristics of in-patients who died by suicide have changed over time. METHODS: We identified all in-patients in England who died by suicide between 2009 and 2020 from the National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide rates were calculated using data from Hospital Episodes Statistics. RESULTS: The rate of in-patient suicide per 100 000 bed days fell by 41.9% between 2009-2011 and 2018-2020. However, since 2016 the rate has remained static with no significant fall. Rates fell in men, those aged 30-59, and those with schizophrenia and other delusional disorders or personality disorder. Rates also fell for suicide by hanging (including hanging on the ward) and jumping. No falls were seen in suicide rates among women, younger and older age groups, and those with affective disorder. There was no indication of a transfer of risk to the post-discharge period or to home treatment/crisis care. More in-patients in the latter part of the study were aged under 25, were on authorised leave, and had psychiatric comorbidity. CONCLUSIONS: In-patient suicide has significantly fallen since 2009, suggesting patient safety may have improved. The recent slowdown in the fall in rates, however, highlights that renewed preventative efforts are needed. These should include a greater focus on women, younger and older patients, and those with affective disorder. Careful reviews prior to granting leave are important to ensure a safe transition into the community.

Socio-demographic variation in diagnosis of and prescribing for common mental illnesses among children and young people during the COVID-19 pandemic: time series analysis of primary care electronic health records.

BACKGROUND: The impact of the COVID-19 pandemic on the mental health of children and young people (CYP) has been widely reported. Primary care electronic health records were utilised to examine trends in the diagnosing, recording and treating of these common mental disorders by ethnicity and social deprivation in Greater Manchester, England. METHODS: Time-series analyses conducted using Greater Manchester Care Record (GMCR) data examined all diagnosed episodes of anxiety disorders and depression and prescribing of anxiolytics and antidepressants among patients aged 6-24 years. The 41-month observation period was split into three epochs: Pre-pandemic (1/2019-2/2020); Pandemic Phase 1 (3/2020-6/2021); Pandemic Phase 2 (7/2021-5/2022). Rate ratios for all CYP specific to sex, age, ethnicity, and neighbourhood-level Indices of Multiple Deprivation (IMD) quintile were modelled using negative binomial regression. RESULTS: Depression and anxiety disorder rates were highest in females, CYP aged 19-24, and White and 'Other' ethnic groups. During Pandemic Phase 1, rates for these diagnoses fell in all demographic subgroups and then rose to similar levels as those recorded pre-pandemic. In Pandemic Phase 2, rates in Black and Mixed-ethnicity females rose to a significantly greater degree (by 54% and 62%, respectively) than those in White females. Prescribing rates increased throughout the study period, with significantly greater rises observed in non-White females and males. The temporal trends were mostly homogeneous across deprivation quintiles. CONCLUSION: The observed fluctuations in frequency of recorded common mental illness diagnoses likely reflect service accessibility and patients' differential propensities to consult as well as changing levels of distress and psychopathology in the population. However, psychotropic medication prescribing increased throughout the observation period, possibly indicating a sustained decline in mental health among CYP, and also clinicians' responses to problems presented. The comparatively greater increases in frequencies of diagnosis recording and medication prescribing among ethnic minority groups warrants further investigation.

Ethnicity and suicide in England and Wales: a national linked cohort study.

BACKGROUND: Understanding of ethnic disparities in suicide in England and Wales is poor as ethnicity is not recorded on death certificates. Using linked data, we examined variations, by sex, in suicide rates in England and Wales by ethnicity and migrant and descendant status. METHODS: Using the Office for National Statistics 2012-19 mortality data linked to the 2011 census from the Public Health Research Database, we calculated the age-standardised suicide rates by sex for each of the 18 self-identified ethnicity groups in England and Wales. We present rates by age, sex, and methods used for suicide by ethnic group. We estimated age-adjusted and sex-adjusted incidence rate ratios (IRRs) using Poisson regression models for each minority ethnic group compared with the majority population. We involved people with lived experience in the research. FINDINGS: Overall, 31 644 suicide deaths occurred over the study period, including 3602 (11%) in people from minority ethnic backgrounds, with a mean age of death of 43·3 years (SD 17·0, range 13-96). Almost all minority ethnic groups had a lower rate of suicide than the White British majority, apart from individuals who identified as being from a Mixed heritage background or White Gypsy or Irish Travellers. In females who identified as Mixed White and Caribbean, the suicide IRR was 1·79 (95% CI 1·45-2·21) compared with the White British majority; in those who identified as White Gypsy or Irish Travellers, the IRR was 2·26 (1·42-3·58). Rates in males identifying as from these two groups and those identifying as White Irish were similar to the White British majority. Compared with the non-migrant population, migrants had a lower rate of suicide regardless of ethnicity, but in the descendant population, people from a Mixed ethnicity background had a higher risk of suicide than the White British majority. INTERPRETATION: There are ethnic disparities in suicide mortality in England and Wales, but the reasons for this are unclear. The higher rate in previously overlooked minority ethnic groups warrants further attention. FUNDING: Wellcome Trust.

Suicide in individuals with eating disorders who had sought mental health treatment in England: a national retrospective cohort study.

BACKGROUND: Although studies have suggested a high risk of suicide in people with eating disorders, most studies have focused on suicidal ideation and attempts. There is little research on the characteristics of people with eating disorders who died by suicide, nor investigation of trends over time. We aimed to compare the characteristics of patients with eating disorders who died by suicide versus patients with other mental health diagnoses who died by suicide in England and to examine the trends in rates. METHODS: In this national retrospective cohort study, data on all people (aged ≥10 years) who died by suicide in England, UK, between Jan 1, 1997, and Dec 31, 2021, while under the care (within the previous 12 months) of mental health services were obtained from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), in which clinical information is collected via a questionnaire completed by the mental health professional responsible for the patient's care. Incidence of suicide in, and demographic, clinical, and treatment characteristics of, patients with a diagnosis of eating disorder (as recorded by the treating clinician) who died by suicide were compared with patients with other mental health diagnoses who died by suicide within the same timeframe using univariable logistic regression analysis. People with related lived experience were involved in the study design, implementation, interpretation, and writing of the manuscript. FINDINGS: Of 119 446 people for whom NCISH were notified of dying by suicide in England, 30 795 were under the recent care of mental health services, of whom 30 246 had known diagnoses and were included in analyses. Of these individuals, 10 373 (34%) were female and 19 873 (66%) were male; 2236 (8%) were of minority ethnicity; 382 (1%) had a diagnosis of eating disorder and 29 864 (99%) had another mental health diagnosis. Compared with patients with other mental health diagnoses who died by suicide, patients with eating disorders were younger (median age 33 years [range 15-90] vs 45 years [10-100]), more often female (343 [90%] female and 39 [10%] male in the eating disorders group; 10 030 [34%] female and 19 834 [66%] male in the other diagnoses group), and less likely to have evidence of conventional risk factors for suicide such as living alone (odds ratio [OR] 0·68, 95% CI 0·55-0·84). 22 (6%) of 382 were from a minority ethnic group. Patients with an eating disorder were characterised by a greater clinical complexity (eg, self-harm [OR 2·31, 95% CI 1·78-3·00], comorbidity [9·79, 6·81-14·1], and longer duration of illness [1·95, 1·56-2·43]), and were more likely to have died following overdoses (2·00, 1·62-2·45) than patients with other diagnoses. Childhood abuse (52 [37%] of 140) and domestic violence (18 [20%] of 91) were common in patients with eating disorders. Similar to patients with other diagnoses, most (244 [75%] of 326) of those with eating disorders who died by suicide were rated as low risk by clinicians at last contact. The number of suicide deaths in patients with eating disorders rose between 1997 and 2021 (incidence rate ratio [IRR] 1·03, 95% CI 1·02-1·05; p<0·0001), but rates fell when accounting for the greater number of patients entering mental health services (IRR 0·97, 0·95-1·00; p=0·033). INTERPRETATION: This study was focused on people who sought help from mental health services. It did not consider subtypes of eating disorders or include a control group, but it does highlight possible areas for intervention. The comprehensive provision of evidence-based treatment for eating disorders and underlying conditions to address the clinical complexity in these patients might help to reduce suicide. Recognising limitations in clinical risk assessment, addressing early life experiences and current adversities, and appropriate prescribing might also be of benefit. Suicide prevention must remain a priority for eating disorder services and mental health care more widely. FUNDING: The Healthcare Quality Improvement Partnership.

Substance use and self-poisoning in schizophrenia: 11-year findings from a national clinical survey of suicide in mental health patients in the UK.

Suicide is the leading cause of unnatural death among people with schizophrenia. Substance use is a highly prevalent comorbid feature of schizophrenia and a modifiable risk factor for suicide. However, no studies have examined changes in the frequency of substance use or self-poisoning in those who died by suicide over time. Knowing this could support more tailored approaches to reducing specific risk factors and access to means in those with schizophrenia who are at risk of suicide. We conducted an 11-year observational study on a clinical survey of people with schizophrenia in the UK who died by suicide within 12 months of contact with mental health services between 2010 and 2020 (n = 2718). Overall, alcohol, cannabis and stimulants were the most frequently reported substances. The odds of lifetime use significantly increased over time for cannabis, stimulants, heroin, and benzodiazepines. There were differences in socio-demographic, behavioural and clinical factors between those with recent and historical alcohol and drug use before death. Deaths by hanging, jumping and self-poisoning were the most common suicide methods. Though deaths by hanging significantly increased over time, deaths by self-poisoning significantly decreased, especially by means of psychotropic medication and opioids. To improve risk management, clinical efforts should focus on identifying and treating people with schizophrenia using specific substances. Nationwide initiatives for improving safety in prescribing could be contributing to reduced risks of suicide via self-poisoning in this group.

Primary care contact, clinical management and suicide risk following discharge from inpatient mental health care.

BACKGROUND: Evidence is sparse regarding service usage and the clinical management of people recently discharged from inpatient psychiatric care who die by suicide. AIM: To improve understanding of how people discharged from inpatient mental health care are supported by primary care during this high-risk transition. DESIGN & SETTING: A nested case-control study utilising interlinked primary and secondary care records in England for people who died within a year of discharge between 2001 and 2019, matched on age, sex, practice-level deprivation and region with up to 20 living discharged people. METHOD: We described patterns of consultation, prescription of psychotropic medication and continuity of care for people who died by suicide and those who survived. Mutually adjusted relative risk estimates were generated for a range of primary care and clinical variables. RESULTS: Over 40% of patients who died within 2 weeks and 80% who died later had at least one primary care consultation. Evidence of discharge communication from hospital was infrequent. Within-practice continuity of care was relatively high. Those who died by suicide were less likely to consult within two weeks of discharge, AOR 0.61 (0.42-0.89), more likely to consult in the week before death, AOR 1.71 (1.36-2.15), to be prescribed multiple types of psychotropic medication, (AOR 1.73, 1.28-2.33), to experience readmission and have a diagnosis outside of the 'Severe Mental Illness' definition. CONCLUSION: Primary care clinicians have opportunities to intervene and should prioritise patients experiencing transition from inpatient care. Clear communication and liaison between services is essential to provide timely support.

Social services utilisation and referrals after seeking help from health services for self-harm: a systematic review and narrative synthesis.

Objectives: Suicide prevention is a major public health challenge. Appropriate aftercare for self-harm is vital due to increased risks of suicide following self-harm. Many antecedents to self-harm involve social factors and there is strong rationale for social services-based self-harm aftercare. We aimed to review evidence for social service utilisation and referrals among people seeking help following self-harm. Design: Systematic review with narrative synthesis. Data sources: PubMed, PsycINFO, AMED, Social Policy and Practice, EMBASE, Medline, Web of Science, Social Care Online, citation lists of included articles and grey literature. Eligibility criteria: Studies of people of any age in contact with health services following self-harm, with study outcomes including referrals to or utilisation of social workers and social services. Data extraction and synthesis: Information was extracted from each included study using a proforma and quality was critically assessed by two reviewers. Narrative synthesis was used to review the evidence. Results: From a total of 3414 studies retrieved, 10 reports of 7 studies were included. Study quality was generally high to moderate. All studies were based in emergency departments (EDs) and most were UK based. In studies based solely on ED data, low proportions were referred to social services (in most studies, 1%-4%, though it was up to 44% when social workers were involved in ED assessments). In one study using linked data, 15% (62/427) were referred to social services and 21% (466/2,205) attended social services over the subsequent 3-year period. Conclusions: Overall, few patients were referred to social services after self-harm. Higher reported referral rates may reflect greater service availability, involvement of social workers in psychosocial assessments or better capture of referral activity. Social services-based and integrated approaches for self-harm aftercare are important future directions for suicide prevention. Improved links between social services and health services for people seeking support after self-harm are recommended.