Suicide among psychiatric patients who migrated to the UK: a national clinical survey.

Background: Within the UK, limited research has examined migration and suicide risk. To assist with tailoring mental health care to the needs of different migrant groups, it is important to identify the clinical profile and antecedents to suicide. Methods: We focussed on two groups of migrants: those resident in the UK for less than 5 years (recent migrants) and those seeking permission to stay in the UK. Data on mental health patients who died by suicide in the UK between 2011 and 2019 were obtained as part of the National Confidential Inquiry into Suicide and Safety in Mental Health. Findings: 13,948 patients died by suicide between 2011 and 2019: 593 were recent migrants with 48 seeking permission to stay in the UK. The overall suicide rate between 2011 and 2017 for patients seeking to stay was 23.8/100,000 (95% CI 17.3-32.1). There was some uncertainty around this estimate but it appeared higher than the general population suicide rate of 10.6/100,000 population (95% CI 10.5-10.7; p = .0001) for the same period. A higher proportion of migrants were from an ethnic minority group (15% recent migrants vs. 70% seeking to remain vs. 7% non-migrants) and more were viewed as at low long-term risk of suicide (63% recent migrants vs. 76% seeking to remain vs. 57% non-migrants). A higher proportion of recent migrants died within three months of discharge from psychiatric in-patient care (19% vs. 14%) compared to non-migrants. Proportionally more patients seeking to remain had a diagnosis of schizophrenia and other delusional disorders (31% vs. 15%) and more had experienced recent life events compared to non-migrants (71% vs. 51%). Interpretation: A higher proportion of migrants had severe or acute illness at the time of their suicide. This may be linked to a range of serious stressors and/or lack of connection with services that could have identified signs of illness early. However, clinicians often viewed these patients as low risk. Mental health services should consider the breadth of stressors migrants may face and adopt a multi-agency approach to suicide prevention. Funding: The Healthcare Quality Improvement Partnership.

Recent GP consultation before death by suicide in middle-aged males: a national consecutive case series study.

BACKGROUND: Reducing suicide risk in middle-aged males (40-54 years) is a national priority. People have often presented to their GP within 3 months before suicide thus highlighting an opportunity for early intervention. AIM: To describe the sociodemographic characteristics and identify antecedents in middle-aged males who recently consulted a GP before dying by suicide. DESIGN AND SETTING: This study was a descriptive examination of suicide in a national consecutive sample of middle-aged males in 2017 in England, Scotland, and Wales. METHOD: General population mortality data were obtained from the Office for National Statistics and National Records of Scotland. Information was collected about antecedents considered relevant to suicide from data sources. Logistic regression examined associations with final recent GP consultation. Males with lived experience were consulted during the study. RESULTS: In 2017, a quarter (n = 1516) of all suicide deaths were in middle-aged males. Data were attained on 242 males: 43% had their last GP consultation within 3 months of suicide; and a third of these males were unemployed and nearly half were living alone. Males who saw a GP recently before suicide were more likely to have had recent self-harm and work-related problems than males who had not. Having a current major physical illness, recent self-harm, presenting with a mental health problem, and recent work-related issues were associated with having a last GP consultation close to suicide. CONCLUSION: Clinical factors were identified that GPs should be alert to when assessing middle-aged males. Personalised holistic management may have a role in preventing suicide in these individuals.

Bereavement and suicide bereavement as an antecedent of suicide in children and young people: Prevalence and characteristics.

INTRODUCTION: There is limited research into bereavement and suicide bereavement as an antecedent of suicide in young people. METHODS: We extracted information on the antecedents of suicide from official reports, primarily coroner inquests, on a 3-year national consecutive case series of all UK deaths by suicide in people aged 10-19. RESULTS: Between 2014 and 2016, there were 595 suicides by young people. 134 (25%) had been previously or recently bereaved; 51 (9%) by suicide, mainly of a friend or acquaintance. This is equivalent to 1 in 4 and 1 in 11, respectively, of all young people who die by suicide. Bereavement added to existing adversities - many antecedents of suicide were more likely in young people who were bereaved compared to those who were not, but there were few differences in the experiences of young people bereaved by suicide compared to other causes. LIMITATIONS: This was an observational, not a risk factor study, and we did not use a control group. It is difficult to obtain data on non-suicide controls due to the ethical implications in contacting families, and the fact of suicide itself, its impact on disclosure and the reluctance of potential controls distorting any comparisons. CONCLUSION: Lasting bereavement support needs to be routinely and immediately available for young people, including those who have experienced the death of a friend or acquaintance. Vigilance of agencies for bereaved young people is required, especially if there is evidence of other adversities.

An evaluation of Anxiety UK's psychological therapy service outcomes.

BACKGROUND: Anxiety and depression are highly prevalent. The aim was to examine the effectiveness of Anxiety UK's national psychological therapy service; benchmarking against NHS IAPT data. METHODS: We examined psychological therapy outcome data for Anxiety UK clients who completed therapy between April 2019 - March 2020 and benchmarked this against NHS Improving Access to Psychological Therapies (IAPT) outcome data for the same period. Anxiety UK clients completed validated measures of anxiety and depression at two time points: the first and last therapy session. Caseness, recovery, reliable improvement and reliable recovery rates were based on IAPT definitions. RESULTS: 957 clients completed at least two psychological therapy sessions with an Anxiety UK Approved Therapist. Recovery, reliable improvement, and reliably recovered rates exceeded IAPT targets. Depression and anxiety reduced from first to last session. Cognitive behavioural therapy produced the greatest change in anxiety over time compared to counselling and hypnotherapy. The more therapy sessions attended, the greater the change in anxiety and depression scores from the first to last session. LIMITATIONS: For some clients, anxiety and depression levels may have alleviated without therapy. No outcome data were collected following therapy cessation. Therefore, conclusions regarding maintenance and long-term effects of therapy cannot be made. CONCLUSION: Anxiety UK provide highly effective psychological therapies for anxiety and depression. Flexibility in the number of therapy sessions provided is recommended for NHS services and those of external organisations.

Suicide in children and young people: Can it happen without warning?

BACKGROUND: Parents bereaved by suicide often say the death of their loved one happened "out of the blue". It is common for suicide in young people to be preceded by a number of indications of risk, including self-harm, the communication of suicidal ideas, and recent contact with services. We examined whether there is a group of young people who die by suicide without explicit warning signs, and if they indicate risk indirectly, through other suicide risk factors. METHODS: Using national mortality data, we identified a three-year UK national case series of deaths by suicide in people aged 10-19. We extracted information on the antecedents of suicide from coroner inquests and other official investigations into these deaths. RESULTS: There were 595 suicides by young people between 2014 and 2016. We obtained data for 544 (91%). Around a third (n = 161, 30%) had no known history of suicidal ideas or self-harm. This group also had low rates of other risk factors for suicide, including substance misuse, a mental health diagnosis, recent adverse life events, and of contact with services. LIMITATIONS: We relied on information provided to inquests and other investigations: under-reporting, especially on sensitive issues, is likely. Families and other witnesses may have under-reported warning signs that suggest they could have intervened. CONCLUSION: Suicide after minimal warning appears to be relatively common in young people. Suicidal ideas may develop rapidly in this age group and crisis services should therefore be widely available. Future prevention cannot rely on explicit expressions of risk.

Children and young people who die by suicide: childhood-related antecedents, gender differences and service contact.

BACKGROUND: Worldwide suicide is commonest in young people and in many countries, including the UK, suicide rates in young people are rising. AIMS: To investigate the stresses young people face before they take their lives, their contact with services that could be preventative and whether these differ in girls and boys. METHOD: We identified a 3-year UK national consecutive case series of deaths by suicide in people aged 10-19, based on national mortality data. We extracted information on the antecedents of suicide from official investigations, primarily inquests. RESULTS: Between 2014 and 2016, there were 595 suicides by young people, almost 200 per year; 71% were male (n = 425). Suicide rates increased from the mid-teens, most deaths occurred in those aged 17-19 (443, 74%). We obtained data about the antecedents of suicide for 544 (91%). A number of previous and recent stresses were reported including witnessing domestic violence, bullying, self-harm, bereavement (including by suicide) and academic pressures. These experiences were generally more common in girls than boys, whereas drug misuse (odds ratio (OR) = 0.54, 95% CI 0.35-0.83, P = 0.006) and workplace problems (OR 0.52, 95% CI 0.28-0.96, P = 0.04) were less common in girls. A total of 329 (60%) had been in contact with specialist children's services, and this was more common in girls (OR 1.86, 95% CI 1.19-2.94, P = 0.007). CONCLUSIONS: There are several antecedents to suicide in young people, particularly girls, which are important in a multiagency approach to prevention incorporating education, social care, health services and the third sector. Some of these may also have contributed to the recent rise.

Examining the mechanisms by which adverse life events affect having a history of self-harm, and the protective effect of social support.

BACKGROUND: Psychological models of suicide emphasize perceptions of negative stressors, hopelessness and self-harm as key antecedents to suicidal thoughts/acts. Such models also emphasize the potential protective role of social support in these pathways. However, such pathways have not been tested using population level data. Hence, this study aimed to redress this gap. METHODS: Questionnaire data regarding 24,444 patient suicide deaths were analysed. All individuals died between 1996 and 2015 and were seen by secondary mental health services in England within 12 months before their death. Mediation analyses, using fitted logistic regression models, investigated direct and indirect pathways between negative stressors, hopelessness and a proxy measure of suicide, namely, self-harm history. In addition, the buffering effects of social support were examined in these pathways. RESULTS: There was a direct effect of negative life events on suicidal behaviors. Supporting contemporary psychological models of suicide, a mediated effect via hopelessness and a protective effect of social support were identified. Social support buffered the pathway between stressful life events and hopelessness, with hopelessness decreasing as social support increased. LIMITATIONS: Causal inferences are inappropriate as the design was cross-sectional. A proxy measure of suicidality was utilized (history of self-harm) as all individuals had died by suicide. CONCLUSIONS: This is the first time that population data has been used to test psychological pathways to suicidal acts involving negative stressors, hopelessness and social support. Psychological interventions should focus on increasing social support following negative life events together with ameliorating perceptions of hopelessness.

Access to means of lethal overdose among psychiatric patients with co-morbid physical health problems: Analysis of national suicide case series data from the United Kingdom.

BACKGROUND: Many physical health problems are associated with elevated suicide risk whilst also providing access to means of overdose. We aimed to investigate whether psychiatric patients with physical co-morbidities who die by suicide were more likely than those without co-morbidities to self-poison with non-psychotropic medications. METHODS: We analysed data on 14,648 psychiatric patients who died by suicide in England & Wales during 2004-2015, as recorded by the National Confidential Inquiry into Suicide and Safety in Mental Health. Using logistic regression models adjusted for age, gender, ethnicity, and primary drug dependence/misuse we compared patients diagnosed with physical co-morbidities versus those without to assess whether a greater proportion of the former had died by overdose, and medication prescribed to treat such disorders (e.g. opioids, insulin). RESULTS: 24% (n = 3525) were recorded as having physical co-morbidity. A greater proportion of these individuals died by self-poisoning than those without physical co-morbidity (37% vs. 20%, p < .001; adjusted OR 2.47; 95% CI 2.26-2.70), and they were more likely to have used medications for a physical health disorder in overdose (50% vs. 34%; adjusted OR 2.10; 95% CI 1.80-2.46), particularly opioids (30% vs. 22%; p < .001), paracetamol/opioid compounds (11% vs. 7%, p < .001) and insulin (4% vs. 1%, p < .001). LIMITATIONS: Use of survey data may have resulted in under-reporting of physical health problems and/or overdose medications. CONCLUSIONS: Overdose, rather than hanging, is the leading cause of suicide among psychiatric patients with physical co-morbidities, particularly using non-psychotropic medications. There is potential for means restriction in preventing suicide among these patients.

Suicide in children and young people in England: a consecutive case series.

BACKGROUND: There is concern about the mental health of children and young people and a possible rise in suicidal behaviour in this group. We have done a comprehensive national multi-agency study of suicide in under 20s in England. We aimed to establish how frequently suicide is preceded by child-specific and young person-specific suicide risk factors, as well as all-age factors, and to identify contact with health-care and social-care services and justice agencies. METHODS: This study is a descriptive examination of suicide in a national consecutive sample of children and young people younger than 20 years who died by suicide in England between Jan 1, 2014, and April 30, 2015. We obtained general population mortality data from the Office for National Statistics (ONS). We collected information about antecedents considered to be relevant to suicide (eg, abuse, bullying, bereavement, academic pressures, self-harm, and physical health) from a range of investigations and inquiries, including coroner inquest hearings, child death investigations, criminal justice system reports, and the National Health Service, including data on people in contact with mental health services in the 12 months before their death. FINDINGS: 145 suicides in people younger than 20 years were notified to us during the study period, of which we were able to obtain report data about antecedents for 130 (90%). The number of suicides rose sharply during the late teens with 79 deaths by suicide in people aged 18-19 years compared with 66 in people younger than 18 years. 102 (70%) deaths were in males. 92 (63%) deaths were by hanging. Various antecedents were reported among the individuals for whom we had report data, including academic (especially exam) pressures (35 [27%] individuals), bullying (28 [22%]), bereavement (36 [28%]), suicide in family or friends (17 [13%]), physical health conditions (47 [36%]), family problems (44 [34%]), social isolation or withdrawal (33 [25%]), child abuse or neglect (20 [15%]), excessive drinking (34 [26%]), and illicit drug use (38 [29%]). Suicide-related internet use was recorded in 30 (23%) cases. In the week before death 13 (10%) individuals had self-harmed and 35 (27%) had expressed suicidal ideas. 56 (43%) individuals had no known contact with health-care and social-care services or justice agencies. INTERPRETATION: Improved services for self-harm and mental health are crucial to suicide prevention, but the wide range of antecedents emphasises the roles of schools, primary care, social services, and the youth justice system. FUNDING: The Healthcare Quality Improvement Partnership.

What do pharmaceutical industry professionals in Europe believe about involving patients and the public in research and development of medicines? A qualitative interview study.

OBJECTIVES: To explore European-based pharmaceutical industry professionals' beliefs about patient and public involvement (PPI) in medicines research and development (R&D). SETTING: Pharmaceutical companies in the UK, Poland and Spain. PARTICIPANTS: 21 pharmaceutical industry professionals, four based in the UK, five with pan-European roles, four based in Spain and eight based in Poland. METHOD: Qualitative interview study (telephone and face-to-face, semistructured interviews). All interviews were audio taped, translated (where appropriate) and transcribed for analysis using the Framework approach. RESULTS: 21 pharmaceutical industry professionals participated. Key themes were: beliefs about (1) whether patients and the public should be involved in medicines R&D; (2) the barriers and facilitators to PPI in medicines R&D and (3) how the current relationships between the pharmaceutical industry, patient organisations and patients influence PPI in medicines R&D. CONCLUSIONS: Although interviewees appeared positive about PPI, many were uncertain about when, how and which patients to involve. Patients and the public's lack of knowledge and interest in medicines R&D, and the pharmaceutical industry's lack of knowledge, interest and receptivity to PPI were believed to be key challenges to increasing PPI. Interviewees also believed that relationships between the pharmaceutical industry, patient organisations, patients and the public needed to change to facilitate PPI in medicines R&D. Existing pharmaceutical industry codes of practice and negative media reporting of the pharmaceutical industry were also seen as negative influences on these relationships.

What the public knows and wants to know about medicines research and development: a survey of the general public in six European countries.

OBJECTIVES: To explore public knowledge of, and interest in, learning more about medicines R&D in six European countries. DESIGN: Online survey of 6931 members of the public across Europe. METHODS: The survey formed part of a public omnibus survey. A quota sampling approach was used with quotas set according to national census data on age, gender and government region. The survey explored the public's knowledge and awareness of medicines R&D, their interest in learning more and the perceived influences on this. RESULTS: The survey was completed by 6931 members of the public, over 75% of whom reported having no or less than good knowledge of medicines R&D. Males were more likely than females to report good knowledge (17% vs 15%), and knowledge appeared to decrease with age. Those who were currently or had previously been involved in medical research were almost five times more likely to report good knowledge of medicines R&D overall (43% vs 13%). Participants reported good knowledge of medicines safety and clinical trials but little knowledge of pharmacoeconomics. They were most interested in learning more about medicines safety and personalised and predictive medicine and least interested in pharmacoeconomics. Older people, women and respondents with current good knowledge of medicines R&D were most interested in learning more about medicines R&D. CONCLUSIONS: Experience of medical research appears to play a key role in increasing public awareness of and future interest in medicines R&D. Some groups may need to be specifically targeted to increase their awareness of medicines R&D, for example, women expressed great interest in learning more but reported less knowledge than men. It may be useful to explore further the views of those who are currently uninterested in learning more.