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.

Suicide in recently discharged psychiatric patients: a case-control study.

BACKGROUND: Few controlled studies have specifically investigated aspects of mental health care in relation to suicide risk among recently discharged psychiatric patients. We aimed to identify risk factors, including variation in healthcare received, for suicide within 3 months of discharge. METHOD: We conducted a national population-based case-control study of 238 psychiatric patients dying by suicide within 3 months of hospital discharge, matched on date of discharge to 238 living controls. RESULTS: Forty-three per cent of suicides occurred within a month of discharge, 47% of whom died before their first follow-up appointment. The first week and the first day after discharge were particular high-risk periods. Risk factors for suicide included a history of self-harm, a primary diagnosis of affective disorder, recent last contact with services and expressing clinical symptoms at last contact with staff. Suicide cases were more likely to have initiated their own discharge and to have missed their last appointment with services. Patients who were detained for compulsory treatment at last admission, or who were subject to enhanced levels of aftercare, were less likely to die by suicide. CONCLUSIONS: The weeks after discharge from psychiatric care represent a critical period for suicide risk. Measures that could reduce risk include intensive and early community follow-up. Assessment of risk should include established risk factors as well as current mental state and there should be clear follow-up procedures for those who have self-discharged. Recent detention under the Mental Health Act and current use of enhanced levels of aftercare may be protective.

Effects of psychosocial and individual psychological factors on the onset of musculoskeletal pain: common and site-specific effects.

OBJECTIVE: To determine whether adverse psychosocial and individual psychological factors increase the risk of pain across regional sites. METHODS: A prospective study was conducted of newly employed workers from 12 diverse occupational groups. Near to the beginning of subjects' employment, details of work related psychosocial factors and individual psychological distress were obtained by means of a self completed questionnaire. Questionnaire follow up after 12 months provided data on these same exposures and ascertained pain at any of four anatomical sites: the low back, shoulder, wrist/forearm, and knee. RESULTS: Of the original 1081 subjects, 829 (77%) provided full details at the one year follow up. Psychosocial work demands and high levels of individual psychological distress were found to have a common effect across sites. Psychological distress was associated with a doubling of the risk of reported pain (odds ratio = 2.1, 95% confidence interval 1.6 to 2.7), while aspects of job demand, poor support from colleagues, and work dissatisfaction were all associated with increased odds of reported pain onset of between 1.4 and 1.7. These effects were almost all common across the four regional pain sites. CONCLUSIONS: In cohorts of newly employed workers, certain work related psychosocial factors and individual psychological distress are associated with the subsequent reporting of musculoskeletal pain, and generally this effect is common across anatomical sites.

Hip pain onset in relation to cumulative workplace and leisure time mechanical load: a population based case-control study.

OBJECTIVE: In an unselected community sample of adults, to assess the role and importance of exposure to mechanical factors both at work and leisure in the aetiology of hip pain. METHOD: A population based prevalence case-control study. Cases and controls were identified from a population survey of 3847 subjects registered with two general practices in Cheshire, United Kingdom. All subjects received a postal questionnaire which inquired about hip pain during the past month. An occupational history was obtained, including exposure to each of seven physical demands. Information was also obtained on history of participation in eight common sporting activities. RESULTS: 88% of those invited to participate returned a completed questionnaire. The 352 subjects with hip pain were designated as cases, and the remaining 3002 subjects as controls. In people ever employed, hip pain was significantly associated with high cumulative workplace exposure (before onset) of walking long distances over rough ground, lifting/moving heavy weights, sitting for prolonged periods, walking long distances, frequent jumping between different levels, and standing for prolonged periods. Odds ratios (ORs) in the higher exposure categories ranged from 1.46 to 2.65. Cumulative exposure to three sporting activities was significantly associated with hip pain: track and field sports, jogging, and walking, with odds ratios varying between 1.57 to 1.94. On multivariate analysis three factors were independent predictors of hip pain onset: cumulative exposure of sitting for prolonged periods (higher exposure v not exposed: OR=1.82, 95% confidence interval (CI) 1.13 to 2.92), lifting weights >50 lb (23 kg) (OR=1.74, 95% CI 1.06 to 2.86) (both relating to the workplace), and walking as a leisure activity (OR=1.97, 95% CI 1.32 to 2.94). The population attributable risk associated with each of these activities was 21%, 13%, and 16%, respectively CONCLUSIONS: Cumulative exposure to some workplace and sporting "mechanical" risk factors for hip osteoarthritis (OA) appear to be related to hip pain in general-some (but not all) have previously been related to hip OA. Because these are common workplace or leisure time activities their attributable risk is high.

Risk factors for persistent chronic widespread pain: a community-based study.

BACKGROUND: Chronic widespread pain is the cardinal clinical feature of the fibromyalgia syndrome, which, in the majority of clinic patients, is persistent. By contrast, in community-derived patients, pain is persistent in only half of the affected individuals, particularly those with psychological distress. Whether such distress is a consequence of the pain or a manifestation of a wider process of somatization which is associated with the persistence of pain is unclear. OBJECTIVES: We tested in a large, prospective, population-based study the hypothesis that features of somatization predict the persistence of chronic widespread pain. METHODS: In all, 252 (13%) of 1953 adult subjects selected from a population register were classified as having chronic widespread pain based on a detailed questionnaire which included a pain drawing. The patients also completed a number of psychosocial instruments which measure features known to be associated with somatization. Two hundred and twenty-five (91%) of the patients were successfully followed up after 12 months and provided data on pain status using the same instruments. RESULTS: In all, 126 (56%) patients reported chronic widespread pain at follow-up, 74 (33%) reported other pain and 25 (11%) reported no pain. Persistent chronic widespread pain was strongly associated with baseline test scores for high psychological distress and fatigue. In addition, these subjects were more likely to display a pattern of illness behaviour characterized by frequent visits to medical practitioners for symptoms which disrupt daily activities. The prevalence of persistent pain increased with the number of risk factors the subjects were exposed to. CONCLUSIONS: Although almost half of the cases of chronic widespread pain resolved within 1 yr, this study has demonstrated for the first time that those subjects who display features of somatization are more likely to have widespread pain which persists. These findings have implications for the identification and treatment of persons with persistent chronic widespread pain.

Role of mechanical and psychosocial factors in the onset of forearm pain: prospective population based study.

OBJECTIVE: To determine the aetiology of forearm pain. In particular to determine the relative contribution of (a) psychological factors, features of somatisation, and health anxiety and behaviour, (b) work related mechanical factors, and (c) work related psychosocial factors in the onset of forearm pain. DESIGN: 2 year prospective population based cohort study, with retrospective assessment of exposures at work. SETTING: Altrincham, Greater Manchester. PARTICIPANTS: 1953 individuals aged 18-65 years. OUTCOME MEASURES: Forearm pain of new onset. RESULTS: At follow up, 105 (8.3%) participants reported forearm pain of new onset lasting at least one day in the past month. Among these, 67% also reported shoulder pain, 65% back pain, and 45% chronic widespread pain. Increased risks of onset were associated with high levels of psychological distress (relative risk 2.4, 95% confidence interval 1.5 to 3.8), reporting at least two other somatic symptoms (1.7, 0.95 to 3.0), and high scores on the illness behaviour subscale of the illness attitude scales. The two work related mechanical exposures associated with the highest risk of forearm pain in the future were repetitive movements of the arm (4.1, 1.7 to 10) or wrists (3.4, 1.3 to 8.7), whereas the strongest work related psychosocial risk was dissatisfaction with support from colleagues or supervisors (4.7, 2. 2 to 10). CONCLUSIONS: Psychological distress, aspects of illness behaviour, and other somatic symptoms are important predictors of onset of forearm pain in addition to work related psychosocial and mechanical factors. Misleading terms such as "cumulative trauma disorder" or "repetitive strain injury," implying a single uniform aetiology, should be avoided.

The prevalence and associated features of chronic widespread pain in the community using the 'Manchester' definition of chronic widespread pain.

OBJECTIVE: We examine the descriptive epidemiology of chronic widespread pain using the 'Manchester' definition [CWP(M)] and assess psychosocial and other features which characterize subjects with such pain according to these more stringent criteria. METHODS: A population postal survey of 3004 subjects was conducted in the Greater Manchester area of the UK. RESULTS: The point prevalence of Manchester-defined chronic widespread pain was 4.7%. CWP(M) was associated with psychological disturbance [risk ratio (RR) = 2.2, 95% confidence interval (CI) (1.4-3.5)], fatigue [RR = 3.8, 95% CI (2.3-6.1)], low levels of self-care [RR = 2.2, 95% CI (1.4-3.6)] and with the reporting of other somatic symptoms [RR = 2.0, 95% CI (1.3-3.1)]. Hypochondriacal beliefs and a preoccupation with bodily symptoms were also associated with the presence of CWP(M). CONCLUSION: This definition of chronic widespread pain is more precise in identifying subjects with truly widespread pain and its associated adverse psychosocial factors. Clear associations with other 'non-pain' somatic symptoms were identified, which further supports the hypothesis that chronic widespread pain is one feature of somatization.

Chronic widespread pain in the community: the influence of psychological symptoms and mental disorder on healthcare seeking behavior.

OBJECTIVE: To determine whether psychological symptoms and mental disorder are an intrinsic part of the chronic widespread pain syndrome or whether they have been observed in clinic attenders primarily because of their influence on the decision to seek a medical consultation. METHODS: A population survey of 1953 subjects was conducted in the Greater Manchester area of the United Kingdom. The survey included a postal questionnaire, and in a subgroup of respondents with high levels of distress, the presence of mental disorder was assessed by a semistructured standardized interview. Subjects with chronic widespread pain were classified according to whether they had sought a medical consultation for the reported pain ("consulters") or not ("nonconsulters"). RESULTS: In all, 252 subjects (13%) satisfied American College of Rheumatology criteria for chronic widespread pain, and of these 72% reported having consulted a general practitioner about this pain. There was a clear difference in levels of psychological distress, measured by the General Health Questionnaire (GHQ), between consulters, nonconsulters, and those with no pain. Consulters did not differ from nonconsulters in terms of levels of fatigue, social dysfunction, or number of somatic symptoms reported. Although consulters (among whom one in 4 had a mental disorder) were more likely to have a mental disorder than subjects without pain [OR = 4.9, 95% CI (2.6, 9.5)] the increase in risk comparing consulters to nonconsulters [OR = 2.1, 95% CI (0.7, 5.9)] and nonconsulters to subjects without pain [OR = 1.4, 95% CI (0.7, 2.6)] was not significant. CONCLUSION: The results suggest that psychological distress is associated with chronic widespread pain in addition to any effect on whether consultation is sought for symptoms. The finding that one-quarter of consulters to primary care with chronic widespread pain have a mental disorder should alert primary care physicians and rheumatologists to screen for mental disorder in this group.

Predictors of chronic shoulder pain: a population based prospective study.

OBJECTIVE: To determine the natural history of shoulder pain in the population, and predictors of outcome on the basis of clinical and individual factors. In addition, to determine whether outcome is influenced by the definition of shoulder pain used. METHODS: A prospective cohort study, over a 3 year period, of subjects recruited from a cross sectional population screening study of shoulder pain, conducted in the Greater Manchester area of the UK. RESULTS: Of 92 subjects classified as having shoulder pain in the cross sectional study, 50 (54%) reported shoulder pain at followup about 3 years later. In 90% of cases this was accompanied by some disability specifically relating to the symptoms. Baseline factors that predicted symptoms at followup were: pain (indicated on a manikin) within a more narrowly defined shoulder region, shoulder pain related disability, pain on the day of examination, symptoms lasting more than one year, and a high score on the General Health Questionnaire, a measure of psychological distress. CONCLUSION: Shoulder pain in the population is a longterm disabling symptom, although many subjects do not seek early medical consultation. Disability (independent of whether there was restriction of movement on examination) is a strong predictor of continuing symptoms. The outcome observed in epidemiological studies of shoulder pain will be influenced by the initial definition of symptoms.