Relative toxicity of mood stabilisers and antipsychotics: case fatality and fatal toxicity associated with self-poisoning.

BACKGROUND: Bipolar and other psychiatric disorders are associated with considerably increased risk of suicidal behaviour, which may include self-poisoning with medication used to treat the disorder. Therefore, choice of medication for treatment should include consideration of toxicity, especially for patients at risk. The aim of this study was to estimate the relative toxicity of specific drugs within two drug categories, antipsychotics and mood stabilizers, using large-scale databases to provide evidence that could assist clinicians in making decisions about prescribing, especially for patients at risk of suicidal behaviour. METHOD: Two indices were used to assess relative toxicity of mood stabilisers and antipsychotics: case fatality (the ratio between rates of fatal and non-fatal self-poisoning) and fatal toxicity (the ratio between rates of fatal self-poisoning and prescription). Mood stabilisers assessed included lithium [reference], sodium valproate, carbamazepine, and lamotrigine, while antipsychotics included chlorpromazine [reference], clozapine, olanzapine, quetiapine and risperidone. Fatal self-poisoning (suicide) data were provided by the Office for National Statistics (ONS), non-fatal self-poisoning data by the Multicentre Study of Self-harm in England, and information on prescriptions by the Clinical Practice Research Datalink. The primary analysis focussed on deaths due to a single drug. Cases where the drug of interest was listed as the likely primary toxic agent in multiple drug overdoses were also analysed. The study period was 2005-2012. RESULTS: There appeared to be little difference in toxicity between the mood stabilisers, except that based on case fatality where multiple drug poisonings were considered, carbamazepine was over twice as likely to result in death relative to lithium (OR 2.37 95% CI 1.16-4.85). Of the antipsychotics, clozapine was approximately18 times more likely to result in death when taken in overdose than chlorpromazine (single drug case fatality: OR 18.53 95% CI 8.69-39.52). Otherwise, only risperidone differed from chlorpromazine, being less toxic (OR 0.06 95% CI 0.01-0.47). CONCLUSIONS: There was little difference in toxicity of the individual mood stabilisers. Clozapine was far more toxic than the other antipsychotics. The findings are relevant to prescribing policy, especially for patients at particular risk of suicidal behaviour.

Measuring geographical accessibility to palliative and end of life (PEoLC) related facilities: a comparative study in an area with well-developed specialist palliative care (SPC) provision.

BACKGROUND: Geographical accessibility is important in accessing healthcare services. Measuring it has evolved alongside technological and data analysis advances. High correlations between different methods have been detected, but no comparisons exist in the context of palliative and end of life care (PEoLC) studies. To assess how geographical accessibility can affect PEoLC, selection of an appropriate method to capture it is crucial. We therefore aimed to compare methods of measuring geographical accessibility of decedents to PEoLC-related facilities in South London, an area with well-developed SPC provision. METHODS: Individual-level death registration data in 2012 (n = 18,165), from the Office for National Statistics (ONS) were linked to area-level PEoLC-related facilities from various sources. Simple and more complex measures of geographical accessibility were calculated using the residential postcodes of the decedents and postcodes of the nearest hospital, care home and hospice. Distance measures (straight-line, travel network) and travel times along the road network were compared using geographic information system (GIS) mapping and correlation analysis (Spearman rho). RESULTS: Borough-level maps demonstrate similarities in geographical accessibility measures. Strong positive correlation exist between straight-line and travel distances to the nearest hospital (rho = 0.97), care home (rho = 0.94) and hospice (rho = 0.99). Travel times were also highly correlated with distance measures to the nearest hospital (rho range = 0.84-0.88), care home (rho = 0.88-0.95) and hospice (rho = 0.93-0.95). All correlations were significant at p < 0.001 level. CONCLUSIONS: Distance-based and travel-time measures of geographical accessibility to PEoLC-related facilities in South London are similar, suggesting the choice of measure can be based on the ease of calculation.

Place of death in children and young people with cancer and implications for end of life care: a population-based study in England, 1993-2014.

BACKGROUND: Efforts to improve end of life care (EoLC) have made tangible impacts on care in adults, including enabling more people to die at their preferred place of death (PoD), usually home or hospices. Little is known how the PoD in children and young people (CYP, ≤24 years) has changed over time, especially in the context of a series of national initiatives for EoLC improvement since the late 1990s. To inform evidence-based policy-making and service development, we evaluated the national trends of PoD and the associated factors in CYP who died with cancer. METHODS: Population-based observational study in the National Health Service (NHS) England, 1993-2014. All non-accidental CYP deaths with cancer (N = 12,774) were extracted from the death registration database of the Office for National Statistics (ONS). RESULTS: Hospital deaths reduced from >50 to 45 %, hospice deaths were rare but more than doubled from 6 % in 1993-2000 to 13 % in 2005-2014, and home deaths fluctuated at around 40 %. Those aged 0-19 years were more likely to die at home than young adults (adjusted proportion ratio (PRs): 1.23-1.62); haematological cancer patients or those with 2+ comorbid conditions had higher chances of hospital death (PRs for home: 0.18-0.75, hospice: 0.04-0.37); deprivation was associated with a reduced chance of home death (PRs: 0.76-0.84). The residential region affected hospice but not home deaths. The variations of PoD by cause of death, comorbid conditions and deprivation slightly decreased with time. CONCLUSIONS: Hospitals and home were the main EoLC settings for CYP with cancer. Home death rates barely changed in the past two decades; deaths in hospitals remained the most common but slightly shifted towards hospices. CYP with haematological malignancy or with comorbid conditions had persistently high hospital deaths; these cases had an even lower chance of deaths in hospices (50 %) than at home. There were deprivation- and area-related inequalities in PoD which may need service- and/or policy-level intervention. The findings highlight a need for CYP specific initiatives to enhance EoLC support and capacities both at home and in hospices.

Six-year follow-up of impact of co-proxamol withdrawal in England and Wales on prescribing and deaths: time-series study.

BACKGROUND: The analgesic co-proxamol (paracetamol/dextropropoxyphene combination) has been widely involved in fatal poisoning. Concerns about its safety/effectiveness profile and widespread use for suicidal poisoning prompted its withdrawal in the UK in 2005, with partial withdrawal between 2005 and 2007, and full withdrawal in 2008. Our objective in this study was to assess the association between co-proxamol withdrawal and prescribing and deaths in England and Wales in 2005-2010 compared with 1998-2004, including estimation of possible substitution effects by other analgesics. METHODS AND FINDINGS: We obtained prescribing data from the NHS Health and Social Care Information Centre (England) and Prescribing Services Partneriaeth Cydwasanaethau GIG Cymru (Wales), and mortality data from the Office for National Statistics. We carried out an interrupted time-series analysis of prescribing and deaths (suicide, open verdicts, accidental poisonings) involving single analgesics. The reduction in prescribing of co-proxamol following its withdrawal in 2005 was accompanied by increases in prescribing of several other analgesics (co-codamol, paracetamol, codeine, co-dydramol, tramadol, oxycodone, and morphine) during 2005-2010 compared with 1998-2004. These changes were associated with major reductions in deaths due to poisoning with co-proxamol receiving verdicts of suicide and undetermined cause of -21 deaths (95% CI -34 to -8) per quarter, equating to approximately 500 fewer suicide deaths (-61%) over the 6 years 2005-2010, and -25 deaths (95% CI -38 to -12) per quarter, equating to 600 fewer deaths (-62%) when accidental poisoning deaths were included. There was little observed change in deaths involving other analgesics, apart from an increase in oxycodone poisonings, but numbers were small. Limitations were that the study was based on deaths involving single drugs alone and changes in deaths involving prescribed morphine could not be assessed. CONCLUSIONS: During the 6 years following the withdrawal of co-proxamol in the UK, there was a major reduction in poisoning deaths involving this drug, without apparent significant increase in deaths involving other analgesics.

Social inequalities in alcohol-related adult mortality by National Statistics Socio-economic Classification, England and Wales, 2001-03.

BACKGROUND: This article is the first analysis of the social inequalities in adult alcohol-related mortality in England and Wales at the start of the 21st century, using the National Statistics Socio-economic Classification (NS-SEC). It presents the socio-economic patterns of alcohol-related mortality by gender, age and region, for England and Wales as a whole, Wales and the regions of England. METHODS: Death registrations provided the number of deaths for working age adults, using the National Statistics definition of alcohol-related mortality. Population estimates for England and Wales in 2001-03 were used to estimate alcohol-related mortality rates by sex, five-year age group, NS-SEC and region. Inequalities were measured using ratios of alcohol-related mortality rates between the least and most advantaged classes. RESULTS: There were substantial socio-economic variations in adult alcohol-related mortality, with the inequalities being greater for women than for men. The mortality rate of men in the Routine class was 3.5 times those of men in Higher and Managerial occupations, while for women the corresponding figure was 5.7 times. Greater socio-economic inequalities in mortality were observed for men aged 25-49 than for men aged 50-64; however the highest mortality rate of men occurred for Routine workers aged 50-54. Women in the Routine class experienced mortality rates markedly higher than other classes. The highest mortality rate of women also occurred for Routine workers, but at a younger age than for men (45-49). Within England, the North-West showed the largest inequalities, with particularly high rates in the Routine class for both sexes. In general, there was no association between levels of mortality and socio-economic gradients in mortality across the English regions and Wales. CONCLUSIONS: Rates of alcohol-related mortality in England and Wales increased significantly for people between the early 1990s and early 21st century, and were substantially greater for those in more disadvantaged socio-economic classes. There is also evidence that these socio-economic differences were greater at younger ages, especially for men at ages 25-49.

Variations in life expectancy between rural and urban areas of England, 2001-07.

BACKGROUND: This study was part of a wider project commissioned by the Department for Environment, Food and Rural Affairs (Defra) to examine inequalities in health outcomes in rural areas. It investigated variations in life expectancy at birth between rural and urban areas of England, taking the effect of deprivation into account. The study aimed to produce results which provide specific evidence of the needs of rural communities, as they have often been overlooked in previous research. METHODS: The Rural and Urban Area Classification (RUAC) 2004 and the Index of Multiple Deprivation (IMD) 2007 were used to categorise area types at the Lower Super Output Area (LSOA) level. Population and mortality data used were produced by the Office for National Statistics (ONS). Abridged life tables were constructed to calculate period life expectancy at birth for males and females, for the years 2001 to 2007 combined. Confidence intervals (95%) were also produced. RESULTS: For the 2001-07 period, life expectancy at birth in England was 76.9 years for males and 81.3 years for females. However, when deprivation was examined, results between the most deprived and least deprived quintiles varied by 7.8 years for men and 5.4 years for women.Overall, life expectancy was higher in rural areas than in urban areas. Deprivation had a considerable impact on the results and wide inequalities were evident, particularly in men and in urban areas. In both area types, males living in the less deprived quintiles had similar life expectancies to females living in the more deprived quintiles.Within rural area types, life expectancy was higher in village and dispersed settlements than in town and fringe areas. There were large differences between the fourth and fifth (most deprived) quintiles in village and dispersed settlements, which shows that there may be acute pockets of deprivation within this area type that need to be addressed.In terms of sparsity, there was little difference in life expectancy between densely and less densely populated localities within rural and urban areas. However, variations were observed when deprivation was taken into account and greater differences were evident in less sparse areas than in sparse areas. CONCLUSIONS: There were clear inequalities in life expectancy between rural and urban areas in England. There were also intricate differences within area types, which can be overlooked when only examining differences between them. The results were consistent with the findings of previous studies and demonstrated that it is important to examine differences in life expectancy in both area and deprivation contexts.

Exploratory analysis of seasonal mortality in England and Wales, 1998 to 2007.

BACKGROUND: This article reports research carried out to inform possible methods of describing seasonal mortality in relation to extremes of temperature. In particular, since different methods are currently used to assess excess winter mortality and heatwave related mortality, we aimed to find out whether a single method could be used to measure all seasonal mortality in relation to temperature. In order to do this the project investigated whether there are temperatures above or below which excess deaths occur, and explored whether it is possible to predict reliably how many deaths would occur at extreme temperatures. METHODS: Daily and monthly Central England Temperatures for 1998 to 2007 were supplied by the Met Office Hadley Centre and daily death occurrence data between 1993 and 2007 was extracted from the death registrations database held by the Office for National Statistics (ONS). Least squares regression, based on the previous five years of data, was used to predict expected mortality, and excess mortality was calculated as the difference between the expected mortality and the observed mortality on any given day. Statistically significant increases in both daily deaths and temperatures were investigated with the probability of excess mortality assessed on those days. Two regression models were calculated, one for deaths and temperature and one for excess deaths and temperature. RESULTS: Five days with statistically significant excess mortality were identified over the period 1 January 1998 to 31 December 2007, the largest being on 31 December 1999. Three of the five days identified coincided with extremely hot weather occurring in August 2003 and July 2006. However, more extreme temperatures were seen on some days with no excess mortality, so predicting mortality using extreme temperatures alone would cause frequent false positive results. Regression models based on daily death and temperature explained only 8 per cent of the variance in summer mortality and 7 per cent of the variance in winter mortality. The models based on excess deaths and temperature explained 20 per cent of the variance in excess mortality in summer, but only 1 per cent of the variance in excess mortality in winter. CONCLUSION: There is a weak but significant relationship between temperature and mortality in both the summer and winter months. While in winter mortality does increase as it gets colder, winter mortality is variable and high mortality can occur on relatively mild days. Similarly, in the summer high temperatures are often associated with relatively increased mortality, but a single hot day does not always lead to excess deaths. Daily mortality cannot be predicted from temperature alone: the prevalence of influenza in winter and factors such as air pollution in summer should also be considered.

Relative toxicity of analgesics commonly used for intentional self-poisoning: A study of case fatality based on fatal and non-fatal overdoses.

BACKGROUND: Analgesics are used most frequently in fatal and non-fatal medicinal self-poisonings. Knowledge about their relative toxicity in overdose is important for clinicians and regulatory agencies. METHODS: Using data for 2005-2012 we investigated case fatality (number of suicides relative to number of non-fatal self-poisonings) of paracetamol, aspirin, codeine, dihydrocodeine, tramadol, paracetamol with codeine (co-codamol), paracetamol with dihydrocodeine (co-dydramol), ibuprofen and co-proxamol (paracetamol plus dextropropoxyphene; withdrawn in the UK in 2008 due to high toxicity). Data on suicides obtained from the Office for National Statistics and on non-fatal self-poisonings from the Multicentre Study of Self-harm in England. Case fatality was estimated for each drug, using paracetamol as the reference category. RESULTS: Compared to paracetamol and based on single drug deaths the case fatality index of dihydrocodeine was considerably elevated (odds ratio (OR) 12.81, 95% Confidence Interval (CI) 10.19-16.12). Case fatality indices for tramadol (OR 4.05, 95% CI 3.38-4.85) and codeine (OR 2.21, 95% CI 1.81-2.70) were also significantly higher than for paracetamol. The results when multiple drug deaths were included produced similar results. The relative toxicity of co-proxamol far exceeded that of the other analgesics. LIMITATIONS: Data on fatal self-poisonings were based on national data, whereas those for non-fatal poisonings were based on local data. CONCLUSIONS: Dihydrocodeine and tramadol are particularly toxic in overdose and codeine is also relatively toxic. They should be prescribed with caution, particularly to individuals at risk of self-harm.

Geographical variations in premature mortality in England and Wales, 1981-2006.

Levels of premature mortality in England and Wales have declined markedly over time, with the probability of survival to age 75 increasing from 38 to 66 per cent for males, and from 54 to 77 per cent for females, between 1950 and 2004. To assess the application of this measure to monitor premature mortality in sub-national geographical areas, this article presents an analysis of the probability of survival at local authority level. Results for 1981-83 and 2004-06 are presented for Government Office Regions in England, Wales and local authorities in England and Wales. Significant differences in premature mortality are described within, and between, regions. Patterns of probability of survival to age 75 for local authorities are compared with other measures of mortality.

Relative toxicity of benzodiazepines and hypnotics commonly used for self-poisoning: An epidemiological study of fatal toxicity and case fatality.

The relative toxicity of anxiolytic and hypnotic drugs commonly used for self-poisoning was assessed using data on suicides, prescriptions and non-fatal self-poisonings in England, 2005-2012. Data on suicide by self-poisoning were obtained from the Office for National Statistics, information on intentional non-fatal self-poisoning was derived from the Multicentre Study of Self-harm in England and data on prescriptions in general practice from the Clinical Practice Research Datalink. We used two indices of relative toxicity: fatal toxicity (the number of fatal self-poisonings relative to the number of individuals prescribed each drug) and case fatality (the number of fatal relative to non-fatal self-poisonings). Diazepam was the reference drug in all analyses. Temazepam was 10 times (95% confidence interval 5.48-18.99) and zopiclone/zolpidem nine times (95% confidence interval 5.01-16.65) more toxic in overdose than diazepam (fatal-toxicity index). Temazepam and zopiclone/zolpidem were 13 (95% confidence interval 6.97-24.41) and 12 (95% confidence interval 6.62-22.17) times more toxic than diazepam, respectively (case-fatality index). Differences in alcohol involvement between the drugs were unlikely to account for the findings. Overdoses of temazepam and zopiclone/zolpidem are considerably more likely to result in death than overdoses of diazepam. Practitioners need to exercise caution when prescribing these drugs, especially for individuals who may be at risk of self-harm, and also consider non-pharmacological options.

Incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England (the iceberg model of self-harm): a retrospective study.

BACKGROUND: Little is known about the relative incidence of fatal and non-fatal self-harm in young people. We estimated the incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England. METHODS: We used national mortality statistics (Jan 1, 2011, to Dec 31, 2013), hospital monitoring data for five hospitals derived from the Multicentre Study of Self-Harm in England (Jan 1, 2011, to Dec 31, 2013), and data from a schools survey (2015) to estimate the incidence of fatal and non-fatal self-harm per 100 000 person-years in adolescents aged 12-17 years in England. We described these incidences in terms of an iceberg model of self-harm. FINDINGS: During 2011-13, 171 adolescents aged 12-17 years died by suicide in England (119 [70%] male and 133 [78%] aged 15-17 years) and 1320 adolescents presented to the study hospitals following non-fatal self-harm (1028 [78%] female and 977 [74%] aged 15-17 years). In 2015, 322 (6%) of 5506 adolescents surveyed reported self-harm in the past year in the community (250 [78%] female and 164 [51%] aged 15-17 years). In 12-14 year olds, for every boy who died by suicide, 109 attended hospital following self-harm and 3067 reported self-harm in the community, whereas for every girl who died by suicide, 1255 attended hospital for self-harm and 21 995 reported self-harm in the community. In 15-17 year olds, for every male suicide, 120 males presented to hospital with self-harm and 838 self-harmed in the community; whereas for every female suicide, 919 females presented to hospital for self-harm and 6406 self-harmed in the community. Hanging or asphyxiation was the most common method of suicide (125 [73%] of 171), self-poisoning was the main reason for presenting to hospital after self-harm (849 [71%] of 1195), and self-cutting was the main method of self-harm used in the community (286 [89%] of 322). INTERPRETATION: Ratios of fatal to non-fatal rates of self-harm differed between males and females and between adolescents aged 12-14 years and 15-17 years, with a particularly large number of females reporting self-harm in the community. Our findings emphasise the need for well resourced community and hospital-based mental health services for adolescents, with greater investment in school-based prevention. FUNDING: UK Department of Health.

Risk to heroin users of polydrug use of pregabalin or gabapentin.

AIM: To examine the risk to heroin users of also using gabapentin or pregabalin (gabapentoids). DESIGN: Multi-disciplinary study: we (a) examined trends in drug-related deaths and gabapentoid prescription data in England and Wales to test for evidence that any increase in deaths mentioning gabapentin or pregabalin is associated with trends in gabapentoid prescribing and is concomitant with opioid use; (b) interviewed people with a history of heroin use about their polydrug use involving gabapentin and pregabalin; and (c) studied the respiratory depressant effects of pregabalin in the absence and presence of morphine in mice to determine whether concomitant exposure increased the degree of respiratory depression observed. SETTING: England and Wales. PARTICIPANTS: Interviews were conducted with 30 participants (19 males, 11 female). MEASUREMENTS: (a) Office of National Statistics drug-related deaths from 1 January 2004 to 31 December 2015 that mention both an opioid and pregabalin or gabapentin; (b) subjective views on the availability, use, interactions and effects of polydrug use involving pregabalin and gabapentin; and (c) rate and depth of respiration. RESULTS: Pregabalin and gabapentin prescriptions increased approximately 24% per year from 1 million in 2004 to 10.5 million in 2015. The number of deaths involving gabapentoids increased from fewer than one per year prior to 2009 to 137 in 2015; 79% of these deaths also involved opioids. The increase in deaths was correlated highly with the increase in prescribing (correlation coefficient 0.94; 5% increase in deaths per 100 000 increase in prescriptions). Heroin users described pregabalin as easy to obtain. They suggested that the combination of heroin and pregabalin reinforced the effects of heroin but were concerned it induced 'blackouts' and increased the risk of overdose. In mice, a low dose of S-pregabalin (20 mg/kg) that did not itself depress respiration reversed tolerance to morphine depression of respiration (resulting in 35% depression of respiration, P < 0.05), whereas a high dose of S-pregabalin (200 mg/kg) alone depressed respiration and this effect summated with that of morphine. CONCLUSIONS: For heroin users, the combination of opioids with gabapentin or pregabalin potentially increases the risk of acute overdose death through either reversal of tolerance or an additive effect of the drugs to depress respiration.

Suicide and the 2008 economic recession: who is most at risk? Trends in suicide rates in England and Wales 2001-2011.

The negative impacts of previous economic recessions on suicide rates have largely been attributed to rapid rises in unemployment in the context of inadequate social and work protection programmes. We have investigated trends in indicators of the 2008 economic recession and trends in suicide rates in England and Wales in men and women of working age (16-64 years old) for the period 2001-2011, before, during and after the economic recession, our aim was to identify demographic groups whose suicide rates were most affected. We found no clear evidence of an association between trends in female suicide rates and indicators of economic recession. Evidence of a halt in the previous downward trend in suicide rates occurred for men aged 16-34 years in 2006 (95% CI Quarter 3 (Q3) 2004, Q3 2007 for 16-24 year olds & Q1 2005, Q4 2006 for 25-34 year olds), whilst suicide rates in 35-44 year old men reversed from a downward to upward trend in early 2010 (95% CI Q4 2008, Q2 2011). For the younger men (16-34 years) this change preceded the sharp increases in redundancy and unemployment rates of early 2008 and lagged behind rising trends in house repossessions and bankruptcy that began around 2003. An exception were the 35-44 year old men for whom a change in suicide rate trends from downwards to upwards coincided with peaks in redundancies, unemployment and rises in long-term unemployment. Suicide rates across the decade rose monotonically in men aged 45-64 years. Male suicide in the most-to-medium deprived areas showed evidence of decreasing rates across the decade, whilst in the least-deprived areas suicide rates were fairly static but remained much lower than those in the most-deprived areas. There were small post-recession increases in the proportion of suicides in men in higher management/professional, small employer/self-employed occupations and fulltime education. A halt in the downward trend in suicide rates amongst men aged 16-34 years, may have begun before the 2008 economic recession whilst for men aged 35-44 years old increased suicide rates mirrored recession related unemployment. This evidence suggests indicators of economic strain other than unemployment and redundancies, such as personal debt and house repossessions may contribute to increased suicide rates in younger-age men whilst for men aged 35-44 years old job loss and long-term unemployment is a key risk factor.

Identifying probable suicide clusters in wales using national mortality data.

BACKGROUND: Up to 2% of suicides in young people may occur in clusters i.e., close together in time and space. In early 2008 unprecedented attention was given by national and international news media to a suspected suicide cluster among young people living in Bridgend, Wales. This paper investigates the strength of statistical evidence for this apparent cluster, its size, and temporal and geographical limits. METHODS AND FINDINGS: The analysis is based on official mortality statistics for Wales for 2000-2009 provided by the UK's Office for National Statistics (ONS). Temporo-spatial analysis was performed using Space Time Permutation Scan Statistics with SaTScan v9.1 for suicide deaths aged 15 and over, with a sub-group analysis focussing on cases aged 15-34 years. These analyses were conducted for deaths coded by ONS as: (i) suicide or of undetermined intent (probable suicides) and (ii) for a combination of suicide, undetermined, and accidental poisoning and hanging (possible suicides). The temporo-spatial analysis did not identify any clusters of suicide or undetermined intent deaths (probable suicides). However, analysis of all deaths by suicide, undetermined intent, accidental poisoning and accidental hanging (possible suicides) identified a temporo-spatial cluster (p = 0.029) involving 10 deaths amongst 15-34 year olds centred on the County Borough of Bridgend for the period 27(th) December 2007 to 19(th) February 2008. Less than 1% of possible suicides in younger people in Wales in the ten year period were identified as being cluster-related. CONCLUSIONS: There was a possible suicide cluster in young people in Bridgend between December 2007 and February 2008. This cluster was smaller, shorter in duration, and predominantly later than the phenomenon that was reported in national and international print media. Further investigation of factors leading to the onset and termination of this series of deaths, in particular the role of the media, is required.