Online harms? Suicide-related online experience: a UK-wide case series study of young people who die by suicide.

BACKGROUND: Few studies have examined online experience by young people who die by suicide. METHODS: A 3-year UK-wide consecutive case series of all young people aged 10-19 who died by suicide, based on national mortality data. We extracted information on the antecedents of suicide of 544 of these 595 deaths (91%) from official investigations, mainly inquests. RESULTS: Suicide-related online experience was reported in 24% (n = 128/544) of suicide deaths in young people between 2014 and 2016, equivalent to 43 deaths per year, and was more common in girls than boys (OR 1.87, 95% CI 1.23-2.85, p = 0.003) and those identifying as LGBT (OR 2.35, 95% CI 1.10-5.05, p = 0.028). Searching for information about method was most common (n = 68, 13%), followed by posting suicidal ideas online (n = 57, 10%). Self-harm, bereavement (especially by suicide), social isolation, and mental and physical ill-health were more likely in those known to have suicide-related online experience compared to those who did not. 29 (5%) were bullied online, more often girls (OR 2.84, 1.34-6.04, p = 0.007). Online bullying often accompanied face-to-face bullying (n = 16/29, 67%). CONCLUSIONS: Suicide-related online experience is a common, but likely underestimated, antecedent to suicide in young people. Although its causal role is unclear, it may influence suicidality in this population. Mental health professionals should be aware that suicide-related online experience - not limited to social media - is a potential risk for young patients, and may be linked to experiences offline. For public health, wider action is required on internet regulation and support for children and their families.

Suicide by mental health in-patients under observation.

BACKGROUND: Observations in psychiatric in-patient settings are used to reduce suicide, self-harm, violence and absconding risk. The study aims were to describe the characteristics of in-patients who died by suicide under observation and examine their service-related antecedents. METHOD: A national consecutive case series in England and Wales (2006-2012) was examined. RESULTS: There were 113 suicides by in-patients under observation, an average of 16 per year. Most were under intermittent observation. Five deaths occurred while patients were under constant observation. Patient deaths were linked with the use of less experienced staff or staff unfamiliar with the patient, deviation from procedures and absconding. CONCLUSIONS: We identified key elements of observation that could improve safety, including only using experienced and skilled staff for the intervention and using observation levels determined by clinical need not resources.

Suicide risk linked with clinical consultation frequency, psychiatric diagnoses and psychotropic medication prescribing in a national study of primary-care patients.

BACKGROUND: Little is known about the precursors of suicide risk among primary-care patients. This study aimed to examine suicide risk in relation to patterns of clinical consultation, psychotropic drug prescribing, and psychiatric diagnoses. METHOD: Nested case-control study in the Clinical Practice Research Datalink (CPRD), England. Patients aged ⩾16 years who died by suicide during 2002-2011 (N = 2384) were matched on gender, age and practice with up to 20 living control patients (N = 46 899). RESULTS: Risk was raised among non-consulting patients, and increased sharply with rising number of consultations in the preceding year [⩾12 consultations v. 1: unadjusted odds ratio (OR) 6.0, 95% confidence interval (CI) 4.9-7.3]. Markedly elevated risk was also associated with the prescribing of multiple psychotropic medication types (⩾5 types v. 0: OR 62.6, CI 44.3-88.4) and with having several psychiatric diagnoses (⩾4 diagnoses v. 0: OR 31.1, CI 19.3-50.1). Risk was also raised among patients living in more socially deprived localities. The confounding effect of multiple psychotropic drug types largely accounted for the rising risk gradient observed with increasing consultation frequency. CONCLUSIONS: A greater proportion of patients with several psychiatric diagnoses, those prescribed multiple psychotropic medication types, and those who consult at very high frequency might be considered for referral to mental health services by their general practitioners. Non-consulters are also at increased risk, which suggests that conventional models of primary care may not be effective in meeting the needs of all people in the community experiencing major psychosocial difficulties.

Psychiatric in-patient care and suicide in England, 1997 to 2008: a longitudinal study.

BACKGROUND: Psychiatric in-patients are at high risk of suicide. Recent reductions in bed numbers in many countries may have affected this risk but few studies have specifically investigated temporal trends. We aimed to explore trends in psychiatric in-patient suicide over time. METHOD: A prospective study of all patients admitted to National Health Service (NHS) in-patient psychiatric care in England (1997-2008). Suicide rates were determined using National Confidential Inquiry and Hospital Episode Statistics (HES) data. RESULTS: Over the study period there were 1942 psychiatric in-patient suicides. Between the first 2 years of the study (1997, 1998) and the last 2 years (2007, 2008) the rate of in-patient suicide fell by nearly one-third from 2.45 to 1.68 per 100,000 bed days. This fall in rate was observed for males and females, across ethnicities and diagnoses. It was most marked for patients aged 15-44 years. Rates also fell for the most common suicide methods, particularly suicide by hanging on the ward (a 59% reduction). Although the number of post-discharge suicides fell, the rate of post-discharge suicide may have increased by 19%. The number of suicide deaths in those under the care of crisis resolution/home treatment teams has increased in recent years to approximately 160 annually. CONCLUSIONS: The rate of suicide among psychiatric in-patients in England has fallen considerably. Possible explanations include falling general population rates, changes in the at-risk population or improved in-patient safety. However, a transfer of risk to the period after discharge or other clinical settings such as crisis resolution teams cannot be ruled out.

Characteristics of and trends in subgroups of prisoner suicides in England and Wales.

BACKGROUND: The suicide rate is higher in prisoners compared with the general population. The aim was to describe the characteristics of and longitudinal trends in prisoner suicides in England and Wales. METHOD: A case series was ascertained from the Safer Custody and Offender Policy Group at the Ministry of Justice and included a 9-year (1999-2007) national census of prisoner suicides. Questionnaires were completed by prison staff on sociodemographic, custodial, clinical and service-level characteristics of the suicides. RESULTS: There was a fall in the number of prison suicides and a decline in the proportion of young prisoner (18-20 years) suicides over time. Females were over-represented. Upward trends were found in prisoners with a history of violence and with previous mental health service contact. A downward trend was found in those with a primary psychiatric diagnosis of drug dependence. Drug dependence was found to be significant in explaining suicides within the first week of custody. CONCLUSIONS: The findings provide an important insight to aid a target set in the National Suicide Prevention Strategy in England to reduce suicides in the prisoner population by 20% and highlight an important area for policy development in mental health services. Examining trends identified subgroups that may require improved mental healthcare and recognized those that appeared to be having their treatment needs more adequately met. Evidence suggests that targeted suicide prevention strategies for subgroups of prisoners are required.

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.

Suicide in recently released prisoners: a case-control study.

BACKGROUND: Recently released prisoners are at markedly higher risk of suicide than the general population. The aim of this study was to identify key risk factors for suicide by offenders released from prisons in England and Wales. METHOD: All suicides committed by offenders within 12 months of their release from prison in England and Wales, between 2000 and 2002, were identified. One control matched on gender and date of release from prison was recruited for each case. Univariate and multivariate logistic regression modelling identified key independent risk factors for suicide. RESULTS: Of 256 920 released prisoners, 384 suicides occurred within a year of release. Factors significantly associated with post-release suicide were increasing age over 25 years, released from a local prison, a history of alcohol misuse or self-harm, a psychiatric diagnosis, and requiring Community Mental Health Services (CMHS) follow-up after release from prison. Non-white ethnicity and a history of previous imprisonment were protective factors. CONCLUSIONS: There is a need to improve the continuity of care for people who are released from prison and for community health, offender and social care agencies to coordinate care for these vulnerable individuals.

The personality disorder patient pathway: Service user and clinical perspectives.

AIMS: There have been recent policy developments and research into care provision for service users with personality disorder. However, few studies have focused on service user and staff perspectives on how services could be improved. METHODS: A qualitative study was undertaken in the UK between 2016 and 2017. We conducted six focus groups with clinicians in mental health services with experience of working with people with personality disorder. Using an online survey, we asked current and past service users with personality disorder to describe their experiences of mental health services and make recommendations for improvements. A thematic analysis was conducted. RESULTS: Forty-five clinicians participated in the focus group and 131 service users contributed to the online survey. The main areas of concern identified by both staff and patients were the diagnosis of personality disorder, the absence of a coherent care pathway, access to psychological treatment and staff training. CONCLUSIONS: The care pathway for individuals with personality disorder is unclear to clinicians and service users, and elements of the pathway are disjointed and not working as effectively as they could. Guidelines recommended by National Institute for Health and Care Excellence are not being followed. Specialist psychological interventions should be available to ensure consistent and stable care provision. © 2019 John Wiley & Sons, Ltd.

Length of stay and recidivism in schizophrenia: a study of public psychiatric hospital patients.

OBJECTIVE: Psychiatric beds in public hospitals have decreased 80% since 1955, but admissions have risen correspondingly, largely because of high recidivism rates. Decreases in numbers of beds have been partly achieved by shortening the length of stay, which lessened by half between 1970 and 1980. This study was undertaken to determine whether duration of hospital treatment affects the rate and rapidity of relapse among schizophrenic patients. METHOD: Data on 1,500 patients from 10 state hospitals were gathered for 18 months after initial discharge. Predictor variables included age, sex, marital status, race, number of previous admissions, location of the facility, and length of stay. Data were analyzed by survival analysis with a Cox regression model for two times to initial relapse: 30 days and 18 months (outcome). RESULTS: Length of stay was significantly related to each time to relapse after the effects of number of previous admissions and age were partialed out. Facility location was not predictive, but intrahospital effects were tested by examining the data on the largest facility; again, length of stay significantly predicted relapse. CONCLUSIONS: Although the magnitude of the effect was small, the clinical significance of the findings is the greater likelihood that brief-stay patients will be rehospitalized within 30 days after discharge than will patients treated for longer periods. Brief hospitalization seems generally applicable to psychiatric populations, but there may be a small but important group of seriously mentally ill patients for whom other alternatives are possibly more appropriate and should be explored.

Antigenicity of rat erythrocyte glycophorins.

The relationship between rat red blood cell (RBC) glycophorins and the antigens recognised by anti-rat RBC antibodies was examined. Initially, murine monoclonal antibodies specific for surface epitopes on whole rat RBCs were tested for their reactivity with RBC membranes on Western blots and two were found which reacted with blotted antigens. These antibodies recognised two bands corresponding to the major PAS-stainable bands of rat RBC membranes (i.e., the glycophorins) and a number of minor bands, thus demonstrating that the bands are antigenically related. This band-pattern was remarkably similar to that obtained with mouse anti-rat RBC serum. Digestion with neuraminidase altered the electrophoretic mobility of most of the bands, providing additional evidence that they are sialoglycoproteins, although sialic acid was shown not to contribute to their antigenicity. The glycophorin nature of the major antigens was verified by reelectrophoresis and blotting of bands excised from SDS gels, which showed that they were interconvertible monomeric and dimeric forms of the same polypeptide chain. It is suggested that rat RBC glycophorins are a related family of sialoglycoproteins with the high molecular weight members being formed by dimerization of five lower molecular weight polypeptide chains in various combinations.

On the role of 5-HT1B/1D receptors in modulating transmission in a spinal reflex pathway in the decerebrated rabbit.

1. In decerebrated rabbits, the selective 5-HT1B/1D receptor antagonist GR 127,935 had no significant effects on reflexes evoked in medial gastrocnemius motoneurones by electrical stimulation of the sural nerve, or on arterial blood pressure or heart rate when given by the intrathecal (up to 543 nmol cumulative) or intravenous (up to 1.8 micromol cumulative) routes. 2. In decerebrated, spinalized rabbits, intrathecal GR 127,935 in doses of up to 543 nmol, had no effect on the sural-gastrocnemius reflex. Furthermore, this drug failed to alter enhancement of the sural-gastrocnemius reflex induced by 8-hydroxy-2-(di-n-propyl)aminotetralin (8-OH-DPAT), given at 300 nmol kg-1 i.v. 3. In decerebrated, spinalized rabbits, the selective 5-HT1B/1D receptor agonists L-694,247 (cumulative doses of 2 - 243 nmol kg-1 i.v.) and L-741,604 (cumulative doses of 3 - 307 nmol kg-1 i.v.), each caused the sural-gastrocnemius reflex to increase to 140% of pre-drug levels, and arterial blood pressure to rise by about 10 mmHg. Subsequent administration of GR 127,935 at 0.9 - 1.8 micromol kg-1 reversed the pressor effect of the agonists but not the increase in reflexes. The 5-HT1A receptor antagonist WAY-100,635 (185 nmol kg-1 i.v.) also failed to reverse the increase in reflexes, but the 5-HT1B/1D/5-HT2/5-HT7 ligand ritanserin (1.6 micromol kg-1 i.v.) restored reflexes to pre-drug control values after L-741,604 (it was not tested against L-694,247). 4. These data indicate that 5-HT1B/1D receptors do not significantly modulate transmission in the sural-gastrocnemius reflex pathway, and that the enhancement of reflexes by 8-OH-DPAT and L-741,604 is probably mediated by 5-HT7 receptors.

The neural basis of maternal responsiveness to infants: an fMRI study.

Using fMRI, we examined the neural correlates of maternal responsiveness. Ten healthy mothers viewed alternating blocks of video: (i) 40 s of their own infant; (ii) 20 s of a neutral video; (iii) 40 s of an unknown infant and (iv) 20 s of neutral video, repeated 4 times. Predominant BOLD signal change to the contrasts of infants minus neutral stimulus occurred in bilateral visual processing regions (BA 19,21,37,38); to own infant minus unknown infant in right anterior temporal pole (BA 38), left amygdala and visual cortex (BA 19), and to the unknown infant minus own infant contrast in bilateral orbitofrontal cortex (BA 10,47) and medial prefrontal cortex (BA 8) [corrected] These findings suggest that amygdala and temporal pole may be key sites in mediating a mother's response to her infant and reaffirms their importance in face emotion processing and social behaviour.

Diagnostic criteria in schizophrenia: accentuate the positive.

In a recent article, Andreasen and Flaum (Schizophrenia Bulletin, Vol. 17, No. 1, 1991) argued that greater emphasis should be placed on negative symptoms in the diagnosis of schizophrenia, leading to a less important role for positive symptoms. This article presents a counter-argument to this view. Positive symptoms are common and reliable and therefore highly useful diagnostically. First-rank symptoms, although not specific to schizophrenia, show good discriminability. No other type of symptom or investigative method can make such claims to usefulness. Although positive symptoms do not predict outcome, this is not a necessary function of diagnostic criteria. The predictive power of negative symptoms is, in any case, based largely on studies of patients with chronic disorder. Premorbidly impaired social development may interact with schizophrenia, worsening the prognosis. We believe positive symptoms have always been the essence of psychiatric disorder and should remain so. Increasing the diagnostic weight given to negative symptoms risks restricting the definition of schizophrenia excessively.

A comparison of clinical response to electroconvulsive therapy in puerperal and non-puerperal psychoses.

BACKGROUND: There is a widespread belief that puerperal psychosis is particularly responsive to electroconvulsive therapy (ECT), but research evidence for this is lacking. METHOD: We have conducted a retrospective case-note study of clinical improvement following ECT in puerperal and non-puerperal psychosis. The main outcome measure was improvement in mental state at the end of a course of ECT, rated by a blind rater on a simple four-point scale. Additional indicators of responsiveness to ECT were improvement in mental state 4 weeks after stopping ECT, duration of in-patient stay following ECT and number of ECT received. RESULTS: Women with puerperal psychosis showed greater clinical improvement than women with non-puerperal psychosis. The results were not explained by the greater preponderance of depressive illness in the puerperal group, as the same results were also found when the analysis was confined to women with a clinical diagnosis of depressive illness. CONCLUSION: These findings are the first evidence of a particular sensitivity of ECT in puerperal psychosis. However, they are preliminary and a number of explanations are possible, including good responsiveness to treatment in general. A prospective study using standardised clinical ratings and definitions of key variables is now required. CLINICAL IMPLICATIONS: Clinicians treating severe postpartum illness should continue to regard ECT as a treatment option. LIMITATIONS OF THE STUDY: The study is limited by its reliance on retrospective examination of information recorded in case notes. Ratings of clinical improvement were not standardised.

The psychological autopsy approach to studying suicide: a review of methodological issues.

The psychological autopsy approach to studying suicide is becoming an increasingly used research method. It presents considerable methodological problems. In order to assist future researchers in this field and to help readers assess reports of psychological autopsy studies the authors have reviewed these issues on the basis of their own experience and those of other workers. The areas covered include research design, identification of subjects, sources of information and the particular issues concerned with approaching relatives and other informants, choice and recruitment of controls, the difficulties of conducting psychological autopsy interviews with relatives, problems for interviewers, the selection of appropriate measures to obtain information, and achieving valid and reasonably reliable conclusions from diverse information sources.

The role of depression in pain, psychophysiological syndromes and medically unexplained symptoms associated with chronic fatigue syndrome.

BACKGROUND: The association between depression and pain, function, medically unexplained symptoms and psychophysiological syndromes such as irritable bowel syndrome has not been explored before in chronic fatigue syndrome. METHODS: Cross-sectional controlled study of the current prevalence of psychophysiological syndromes, pain, function and lifetime prevalence of medically unexplained symptoms in 77 out-patients with chronic fatigue syndrome (CFS) without DSM-III-R depression, 42 CFS out-patients with DSM-III-R depression and 26 out-patient with primary DSM-III-R depression. RESULTS: Both CFS groups differed significantly from the primary depression group but not each other in the prevalence of tension headaches (P < 0.001), reporting of widespread bodily pain (P < 0.001) and the number of lifetime medically unexplained symptoms (P < 0.001). The three groups did not significantly differ in the prevalence of irritable bowel syndrome or fibromyalgia. CFS patients with depression were more impaired in social function than other CFS patients. CONCLUSION: Depression is not associated with the reporting of pain, psychophysiological syndromes and medically unexplained symptoms in CFS patients. Depression is associated with decreased social function in CFS patients. LIMITATIONS: Study depended on recall of symptoms, not confirmed by medical records and current investigations. Patients with depression were taking antidepressants. CLINICAL RELEVANCE: Treating depression in chronic fatigue syndrome is unlikely to diminish reporting of pain and medically unexplained symptoms but may improve social function.

Psychiatric morbidity in patients undergoing heart, heart and lung, or lung transplantation.

OBJECTIVES: To determine the rate of psychiatric disorder in people undergoing heart and/or lung transplantation; to identify the associations of psychiatric disorder in this group. METHOD: Preoperative assessments were carried out on an 18-month sample of consecutive admissions to a regional unit for heart and lung transplantation in the UK. Assessment included psychiatric morbidity, sexual dysfunction, quality of life, and demographic and clinical characteristics. RESULTS: Seventy-six of 79 eligible subjects took part in the assessment. Thirty (39%) were suffering from a psychiatric disorder, the most common being major depressive disorder. Forty-four (58%) reported sexual dysfunction. Clinically significant psychiatric morbidity was associated with a history of treatment for mental disorder, unemployment, and length of physical illness. Patients with psychiatric disorder reported poorer quality of life on the SF-36, with lower scores on subscales for general health perception, social functioning, and energy/vitality. CONCLUSION: There is a substantial rate of psychiatric disorder in people undergoing heart and/or lung transplantation. Risk is higher in people with a history of psychiatric vulnerability and current illness-related factors. Preoperative psychiatric assessment and intervention in some patients may be a valuable part of their clinical care.

Research on cognitive complaints and cognitive functioning in patients with chronic fatigue syndrome (CFS): What conclusions can we draw?

People with chronic fatigue syndrome (CFS) complain of difficulties with concentration and memory yet studies suggest that they do not suffer gross deficits in cognitive functioning. Depressed patients make similar cognitive complaints, and there is symptomatic overlap between CFS and depression. Cognitive complaints and depressed mood are positively correlated in CFS patients but, except on tasks which are particularly sensitive to depression, cognitive performance and depression are not. The inconsistency between cognitive complaints and results of tests of cognitive functioning resembles that found in other subject groups and may be due in part to the inappropriate use of laboratory memory tests for assessing "everyday" cognitive functioning. Even when cognitive capacity is intact, cognitive performance may be affected by factors such as arousal, mood, and strategy. In CFS patients, everyday cognitive tasks may require excessive processing resources leaving patients with diminished spare attentional capacity or flexibility.

Attitudes toward motherhood in postnatal depression: development of the Maternal Attitudes Questionnaire.

This article describes the development of the Maternal Attitudes Questionnaire (MAQ), a 14-item self-report instrument measuring cognitions relating to role change, expectations of motherhood, and expectations of the self as a mother in postnatal women. This questionnaire was found to have good test-retest and internal reliability. In a large sample of women (n = 483) at 6-8 weeks postpartum, scores on the questionnaire were highly correlated with scores on the Edinburgh Postnatal Depression Scale (EPDS) and the Revised Clinical Interview Schedule (CIS-R). Cluster analysis demonstrated that, among depressed women with similar symptom scores on the CIS-R, the MAQ discriminated a group with low MAQ scores and a group with high MAQ scores. This finding supports the hypothesis that women who are depressed postnatally are cognitively heterogeneous; such differences may be important in understanding the etiology and determining the treatment of postnatal depression.

The Family Response Questionnaire: a new scale to assess the responses of family members to people with chronic fatigue syndrome.

OBJECTIVE: Family responses to patients with chronic fatigue syndrome (CFS) may influence the course of the disorder and family members themselves are likely to be adversely affected. However, the beliefs and responses of relatives of CFS patients have been under-researched. The aim of this study was to produce an easy-to-administer questionnaire to assess the responses of family members to people with CFS. METHODS: Seventy-eight people, all close relatives of (physician-diagnosed) CFS sufferers, completed the first version of the Family Response Questionnaire (FRQ). RESULTS: Examination of the correlation matrix and a cluster analysis of the items support four scales rather than the original five. The four response scales were labelled: sympathetic-empathic, active engagement, rejecting-hostile, and concern with self. Measures of test-retest and internal reliability were high. Participants found the items both comprehensible and relevant to their experiences of living with people with CFS. CONCLUSION: The new version of the FRQ will be useful in further examination of the responses of CFS on individuals and their families.