Premature Death Among Primary Care Patients With a History of Self-Harm.

PURPOSE: Self-harm is a public health problem that requires a better understanding of mortality risk. We undertook a study to examine premature mortality in a nationally representative cohort of primary care patients who had harmed themselves. METHODS: During 2001-2013, a total of 385 general practices in England contributed data to the Clinical Practice Research Datalink with linkage to Office for National Statistics mortality records. We identified 30,017 persons aged 15 to 64 years with a recorded episode of self-harm. We estimated the relative risks of all-cause and cause-specific natural and unnatural mortality using a comparison cohort of 600,258 individuals matched on age, sex, and general practice. RESULTS: We found an elevated risk of dying prematurely from any cause among the self-harm cohort, especially in the first year of follow-up (adjusted hazard ratio for that year, 3.6; 95% CI, 3.1-4.2). In particular, suicide risk was especially high during the first year (adjusted hazard ratio, 54.4; 95% CI, 34.3-86.3); although it declined sharply, it remained much higher than that in the comparison cohort. Large elevations of risk throughout the follow-up period were also observed for accidental, alcohol-related, and drug poisoning deaths. At 10 years of follow-up, cumulative incidence values were 6.5% (95% CI, 6.0%-7.1%) for all-cause mortality and 1.3% (95% CI, 1.2%-1.5%) for suicide. CONCLUSIONS: Primary care patients who have harmed themselves are at greatly increased risk of dying prematurely by natural and unnatural causes, and especially within a year of a first episode. These individuals visit clinicians at a relatively high frequency, which presents a clear opportunity for preventive action. Primary care patients with myriad comorbidities, including self-harming behavior, mental disorder, addictions, and physical illnesses, will require concerted, multipronged, multidisciplinary collaborative care approaches.

Prevalence and appropriateness of psychotropic medication prescribing in a nationally representative cross-sectional survey of male and female prisoners in England.

BACKGROUND: Mental illness is highly prevalent among prisoners. Although psychotropic medicines can ameliorate symptoms of mental illness, prescribers in prisons must balance clinical needs against risks to safety and security. Concerns have been raised at the large number of prisoners reportedly receiving psychotropic medicines in England. Nonetheless, unlike for the wider community, robust prescribing data are not routinely available for prisons. We investigated gender-specific patterns in the prevalence and appropriateness of psychotropic prescribing in English prisons. METHODS: We studied 6052 men and 785 women in 11 prisons throughout England. This represented 7.9 % of male and 20.5 % of female prisoners nationally. Using a cross-sectional design, demographic and prescription data were collected from clinical records of all prisoners prescribed psychotropic medicines, including hypnotic, anxiolytic, antipsychotic, anti-manic, antidepressant and Central Nervous System stimulant medications. Percentages and 95 % CIs were used to estimate the prevalence of prescribing. The Prescribing Appropriate Indicators tool was used to determine appropriateness. Prevalence Ratios (PR) were generated to make age-adjusted comparisons between prisoners and the general population using a dataset supplied by the Clinical Practice Research Datalink. RESULTS: Overall, 47.9 % (CI 44.4-51.4) of women and 16.9 % (CI 16.0-17.9) of men in prison were prescribed one or more psychotropic medicines. Compared with the general population, age-adjusted prescribing prevalence was six times higher among women (PR 5.95 CI 5.36-6.61) and four times higher among men (PR 4.02 CI 3.75-4.30). Undocumented or unapproved indications for prescriptions, not listed in the British National Formulary, were recorded in a third (34.7 %, CI 32.5-37.0) of cases, most commonly low mood and personality disorder. CONCLUSIONS: Psychotropic medicines were prescribed frequently in prisons, especially among women, and for a wider range of indications than are currently recommended. These findings raise questions about whether the prescribing of psychotropic medicines in prisons is wholly appropriate and proportionate to the level of clinical need. Prisons need to develop a wider array of treatment responses, other than medicines, to effectively tackle mental illness, challenging behaviours and distress.

Do GPs want or need formal support following a patient suicide?: a mixed methods study.

BACKGROUND: Patient suicide can be a devastating event for some general practitioners (GPs). Few guidelines exist to aid or support GPs in the aftermath of patient suicide. AIM: To explore GPs views on how they are affected by a patient suicide and the formal support available to them following a patient suicide. DESIGN: Questionnaires and semi-structured interviews. SETTING: General practices in the northwest of England. METHODS: About 198 semi-structured interviews were conducted as part of a retrospective study. Interviews were transcribed verbatim and analysed using descriptive statistics and a framework thematic approach. RESULTS: GPs were aged between 31 and 67 years, 144 (73%) were male and the number of years in practice varied between 8 and 40 years (median = 24 years). GPs were based at 133 (67%) urban and 65 (33%) rural practices, 30 (15%) were single-handed GP practices and 168 (85%) practices had two or more GPs. About 131 (66%) GPs reported being affected by patient suicide through feelings of grief, guilt and self-scrutiny. A greater number of years in practice may have been protective against these effects. About 54 (27%) GPs reported having mostly 'informal' support from peers or colleagues and support was less available to younger and single handed GPs. CONCLUSIONS: Our findings suggest that the majority of GPs are affected by patient suicide and most seek informal support from their peers and colleagues. Although many indicated that informal support systems were adequate and provided a protective environment, procedures should be developed to ensure the availability of guidelines for those who may require formal support.

Suicide risk in primary care patients diagnosed with a personality disorder: a nested case control study.

BACKGROUND: Personality disorder (PD) is associated with elevated suicide risk, but the level of risk in primary care settings is unknown. We assessed whether PD among primary care patients is linked with a greater elevation in risk as compared with other psychiatric diagnoses, and whether the association is modified by gender, age, type of PD, and comorbid alcohol misuse. METHODS: Using data from the UK Clinical Practice Research Datalink, 2384 suicides were matched to 46,899 living controls by gender, age, and registered practice. Prevalence of PD, other mental disorders, and alcohol misuse was calculated for cases and controls separately and conditional logistic regression models were used to estimate exposure odds ratios. We also fitted gender interaction terms and formally tested their significance, and estimated gender age-specific effects. RESULTS: We found a 20-fold increase in suicide risk for patients with PD versus no recorded psychiatric disorder, and a four-fold increase versus all other psychiatric illnesses combined. Borderline PD and PD with comorbid alcohol misuse were associated with a 37- and 45-fold increased risk, respectively, compared with those with no psychiatric disorders. Relative risks were higher for female than for male patients with PD. Significant risks associated with PD diagnosis were identified across all age ranges, although the greatest elevations were in the younger age ranges, 16-39 years. CONCLUSIONS: The large elevation in suicide risk among patients diagnosed with PD and comorbid alcohol misuse is a particular concern. GPs have a potentially key role to play in intervening with patients diagnosed with PD, particularly in the presence of comorbid alcohol misuse, which may help reduce suicide risk. This would mean working with specialist care, agreed clinical pathways and availability of services for comorbidities such as alcohol misuse, as well as opportunities for GPs to develop specific clinical skills.

Implementation of mental health service recommendations in England and Wales and suicide rates, 1997-2006: a cross-sectional and before-and-after observational study.

BACKGROUND: Research investigating which aspects of mental health service provision are most effective in prevention of suicide is scarce. We aimed to examine the uptake of key mental health service recommendations over time and to investigate the association between their implementation and suicide rates. METHODS: We did a descriptive, cross-sectional, and before-and-after analysis of national suicide data in England and Wales. We collected data for individuals who died by suicide between 1997 and 2006 who were in contact with mental health services in the 12 months before death. Data were obtained as part of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. When denominator data were missing, we used information from the Mental Health Minimum Data Set. We compared suicide rates for services implementing most of the recommendations with those implementing fewer recommendations and examined rates before and after implementation. We stratified results for level of socioeconomic deprivation and size of service provider. FINDINGS: The average number of recommendations implemented increased from 0·3 per service in 1998 to 7·2 in 2006. Implementation of recommendations was associated with lower suicide rates in both cross-sectional and before-and-after analyses. The provision of 24 h crisis care was associated with the biggest fall in suicide rates: from 11·44 per 10 000 patient contacts per year (95% CI 11·12-11·77) before to 9·32 (8·99-9·67) after (p<0·0001). Local policies on patients with dual diagnosis (10·55; 10·23-10·89 before vs 9·61; 9·18-10·05 after, p=0·0007) and multidisciplinary review after suicide (11·59; 11·31-11·88 before vs 10·48; 10·13-10·84 after, p<0·0001) were also associated with falling rates. Services that did not implement recommendations had little reduction in suicide. The biggest falls in suicide seemed to be in services with the most deprived catchment areas (incidence rate ratio 0·90; 95% CI 0·88-0·92) and the most patients (0·86; 0·84-0·88). INTERPRETATION: Our findings suggest that aspects of provision of mental health services can affect suicide rates in clinical populations. Investigation of the relation between new initiatives and suicide could help to inform future suicide prevention efforts and improve safety for patients receiving mental health care. FUNDING: National Patient Safety Agency, UK.

Impact of national policy initiatives on fatal and non-fatal self-harm after psychiatric hospital discharge: time series analysis.

BACKGROUND: Risk of self-harm and suicide is greatly increased in the period after discharge from psychiatric in-patient care. AIMS: To investigate the impact on suicide of a series of policy initiatives to enhance care in the immediate post-discharge period. METHOD: A time series analysis was based on 1997-2007 data from the National Confidential Inquiry into Suicide and from Hospital Episode Statistics for England. RESULTS: There was no evidence of a reduced risk of suicide in the first 12 weeks following discharge in 2003-2007 compared with 1997-2002. In contrast, the relative risk of non-fatal self-harm in the 12 weeks after discharge declined. The risk ratio for self-harm (2003-2007 v. 1997-2002) at 0-1 week post-discharge was 0.86 (95% CI 0.80-0.92) and at 2-4 weeks it was 0.89 (95% CI 0.85-0.94). CONCLUSIONS: These findings provide some support for the impact of recent policy changes on the risk of non-fatal self-harm in the immediate period after discharge from psychiatric in-patient care.

Trends in rates of mental illness in homicide perpetrators.

BACKGROUND: The rise in homicides by those with serious mental illness is of concern, although this increase may not be continuing. AIMS: To examine rates of mental illness among homicide perpetrators. METHOD: A national consecutive case series of homicide perpetrators in England and Wales from 1997 to 2006. Rates of mental disorder were based on data from psychiatric reports, contact with psychiatric services, diminished responsibility verdict and hospital disposal. RESULTS: Of the 5884 homicides notified to the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness between 1997 and 2006, the number of homicide perpetrators with schizophrenia increased at a rate of 4% per year, those with psychotic symptoms at the time of the offence increased by 6% per year. The number of verdicts of diminished responsibility decreased but no change was found in the number of perpetrators receiving a hospital order disposal. The likeliest explanation for the rise in homicide by people with psychosis is the misuse of drugs and/or alcohol, which our data show increased at a similar magnitude to homicides by those with psychotic symptoms. However, we are unable to demonstrate a causal association. Although the Poisson regression provides evidence of an upward trend in homicide by people with serious mental illness between 1997 and 2006, the number of homicides fell in the final 2 years of data collection, so these findings should be treated with caution. CONCLUSIONS: There appears to be a concomitant increase in drug misuse over the period, which may account for this rise in homicide. However, an increase in the number of people in contact with mental health services may suggest that access to mental health services is improving. Previous studies have used court verdicts such as diminished responsibility as a proxy measure of mental disorder. Our data indicate that this does not reflect accurately the prevalence of mental disorder in this population.

Mental illness, gender and homicide: a population-based descriptive study.

In England and Wales, a lifetime history of mental disorder is recorded in almost a third of homicides but mental illness as a defence in homicide cases has recently come under review. In this study, we aimed to compare the social, criminological and clinical characteristics of women and men convicted of homicide and secondly, to understand how pathways through the judicial system differ by gender of the perpetrator, characteristics of the offence and mental illness. A cross sectional study of 4572 convicted homicide perpetrators in England and Wales 1997-2004 was performed. Significantly more women who had committed homicide had a lifetime history of mental illness and were more likely to be mentally ill at the time of offence compared to men. Women more often received non-custodial sentences, whether or not they had mental illness. If the victim were a child or other relative, the courts were more lenient with women. Gender and the presence of mental illness both influence the characteristics of homicide and outcome of the legal process in the UK. Our findings suggest that all perpetrators of homicide should have a psychiatric assessment pre-trial. Psychiatrists need to rate risk objectively in a gender blind way when providing psychiatric reports to be used as evidence in court.

A population-based study of juvenile perpetrators of homicide in England and Wales.

This study aimed to describe the social, behavioural and offence characteristics of all convicted perpetrators of homicide aged 17 and under; to examine their previous contact with mental health services, and to discuss strategies for homicide prevention. An eight-year (1996-2004) sample of 363 juvenile homicide perpetrators in England and Wales was examined. The majority of perpetrators were male, used a sharp instrument, and most victims were acquaintances or strangers. Over half had previously offended. A history of alcohol and/or drug misuse was common, as was the prevalence of family dysfunction, abuse, educational difficulties or discipline problems. Previous contact with mental health services was rare. Earlier intervention targeting social and psychological adversity and substance misuse could help to reduce the level of risk for future violence, and may reduce homicide rates among juveniles. Strengthening engagement with young offenders and increasing resources to prevent recidivism may also be beneficial.

Treatment of Mental Illness Prior to Suicide: A National Investigation of 12,909 patients, 2001-2016.

OBJECTIVE: Previous research suggests that up to 90% of individuals who die by suicide may have a mental disorder at the time of death but that levels of treatment may be low. This study aimed to examine undertreatment among patients with mental health conditions who died by suicide and to assess the association between patients' clinical and sociodemographic characteristics and treatment receipt. METHODS: The study's sample included 12,909 patients in England and Wales who died by suicide within 12 months of contact with mental health services between 2001 and 2016. All patients had received a diagnosis of bipolar affective disorder, schizophrenia, depression, or an anxiety disorder. Records of patients who were not receiving treatment as recommended by national clinical guidelines at the time of death were examined for levels of nonprescription of treatment and nonadherence. RESULTS: Twenty-four percent of the patients did not receive treatment, 11% had not been prescribed treatment, and 13% were nonadherent with treatment. These proportions differed by diagnosis. After adjustment for main primary diagnosis, analyses showed that being under age 40, unemployment, living alone, drug misuse, medication side effects, and comorbid personality disorder were independently associated with a decreased likelihood of receiving treatment. CONCLUSIONS: One-quarter of patients with mental health conditions who die by suicide may not be receiving relevant interventions at the time of death. Levels of and reasons for nontreatment vary by diagnosis, but measures to address comorbid diagnoses and implement interventions to improve adherence in specific groups could have an impact.

Suicide after leaving the UK armed forces--a cohort study.

BACKGROUND: Few studies have examined suicide risk in individuals once they have left the military. We aimed to investigate the rate, timing, and risk factors for suicide in all those who had left the UK Armed Forces (1996-2005). METHODS AND FINDINGS: We carried out a cohort study of ex-Armed Forces personnel by linking national databases of discharged personnel and suicide deaths (which included deaths receiving either a suicide or undetermined verdict). Comparisons were made with both general and serving populations. During the study period 233,803 individuals left the Armed Forces and 224 died by suicide. Although the overall rate of suicide was not greater than that in the general population, the risk of suicide in men aged 24 y and younger who had left the Armed Forces was approximately two to three times higher than the risk for the same age groups in the general and serving populations (age-specific rate ratios ranging from 170 to 290). The risk of suicide for men aged 30-49 y was lower than that in the general population. The risk was persistent but may have been at its highest in the first 2 y following discharge. The risk of suicide was greatest in males, those who had served in the Army, those with a short length of service, and those of lower rank. The rate of contact with specialist mental health was lowest in the age groups at greatest risk of suicide (14% for those aged under 20 y, 20% for those aged 20-24 y). CONCLUSIONS: Young men who leave the UK Armed Forces were at increased risk of suicide. This may reflect preservice vulnerabilities rather than factors related to service experiences or discharge. Preventive strategies might include practical and psychological preparation for discharge and encouraging appropriate help-seeking behaviour once individuals have left the services.

Suicide pacts in the mentally ill: a national clinical survey.

There have been no detailed descriptions of psychiatric patients who have died by suicide pact. We examined the social and clinical characteristics of pact cases in England and Wales using a national clinical survey sample of people who died by suicide pact and who had been in recent (<12 months) contact with mental health services. Over the study period (1996-2005), there were 278 cases of suicide who had died in a pact, 77 (28%) of whom had been in recent service contact. The most common cause of death overall was by carbon monoxide poisoning, but those in contact with services were more likely to use more violent methods compared with other pact victims. Nearly half (47%) had affective disorder and 68% had previously self-harmed. Over a quarter (29%) had died within 3 months of discharge from psychiatric care and 36% had missed their last service appointment. Pact cases were more likely than solitary suicide cases to have experienced recent adverse life events, typically family problems. Measures that may prevent suicide pacts in the mentally ill include the effective treatment of depression and closer supervision in both in-patient and community settings. Awareness of the family environment may contribute to reduced risk.

Trends in wood dust inhalation exposure in the UK, 1985-2005.

OBJECTIVES: Wood dust data held in the Health and Safety Executive (HSE) National Exposure DataBase (NEDB) were reviewed to investigate the long-term changes in inhalation exposure from 1985 to 2005. In addition, follow-up sampling measurements were obtained from selected companies where exposure measurements had been collected prior to 1994, thereby providing a follow-up period of at least 10 years, to determine whether changes in exposure levels had occurred, with key staff being interviewed to identify factors that might be responsible for any changes observed. METHODS: Analysis of the temporal trend in exposure concentrations was performed using Linear Mixed Effect Models on the log-transformed NEDB data set and expressed as the relative annual change in concentration. RESULTS: For the NEDB wood dust data, an annual decline of geometric mean (GM) exposure of 8.1% per year was found based on 1459 exposure measurements collected between 1985 and 2003. This trend was predominantly observed in data from inspection visits (measurements collected on a mandatory basis by a Specialist HSE Inspector) (n = 1009), while data from representative surveys (measurements collected on a voluntary basis to provide information on current practices and exposures) remained relatively stable. Ten follow-up surveys in individual workplaces in 2004-2005 resulted in 70 new measurements and for each of the companies resurveyed, the GM of the wood dust exposure decreased between sampling surveys. CONCLUSION: Analysis of the temporal trend in UK wood dust exposure concentrations revealed declines of 8% per annum. Interviews with key long-serving employees and management suggest that factors such as technological changes in production processes, response to new legislation, and enforcement agency inspections, together with global economic trends, could be linked to the downward trends observed.

Temporal trends of flour dust exposure in the United Kingdom, 1985-2003.

The aim of the study was to examine the long-term changes in inhalation exposure to flour dust in the UK. Flour dust data held in the UK National Exposure DataBase (NEDB) and from one large company from 1985 to 2003 were reviewed. Analysis of the log-transformed data was carried out using linear mixed effect models and expressed as the relative annual change in exposure. 1451 inhalable flour dust measurements were analysed. The overall mean flour dust levels ranged from 7.8 mg m(-3) in the bakeries to 17.9 mg m(-3) in the flour mills. Analysis of the data obtained from NEDB and industry revealed no statistically significant temporal trends in exposure. Considering these high levels have persisted over the last 20 years, there is a need for government and industry to implement further measures aimed at reducing flour dust exposures and the risk of developing occupational asthma.

Suicide in juveniles and adolescents in the United Kingdom.

BACKGROUND: Suicide is a leading cause of death among youths. Comparatively few studies have studied recent trends over time, or examined rates and characteristics of service contact in well-defined national samples. METHODS: Data on general population suicides and mid-year population estimates were used to calculate suicide rates (per 100,000/year) among youths aged 10-19 years in the United Kingdom. We then determined the proportion of youths who had been in mental health service contact in the year prior to death. Social and clinical data were collected via questionnaires sent to clinicians who had provided care. RESULTS: The general population rate of suicide was higher in males than females, and was higher in 15-19-year-olds compared to 10-14-year-olds. Suicide rates for 10-19-year-olds declined by 28% between 1 January 1997 and 31 December 2003 (compared with an 8% reduction in those aged >19 years); the fall was particularly marked for males. Mental health service contact was low at 14% (compared with 26% for adults), especially for males (12%). Youths in mental health contact were characterised by: diagnosis of affective disorder, mental illness history, residential instability, self-harm, and substance misuse. Over half of youths were living with parents and one-fifth were in full-time education. CONCLUSIONS: The suicide rate for 10-19-year-olds in the UK appeared to fall between 1997 and 2003. Further monitoring of suicide rates is needed to determine whether this trend has continued for the most recent years (e.g., 2004-7). The fall in rates may have been related to socio-economic or clinical factors. The rate of contact with services was low compared to adults, particularly in males. This is concerning because young males have the highest suicide rate in the UK. Suicide prevention in young people is likely to require a multi-agency approach.

Suicide in a National Student Mental Health Patient Population, 1997-2012.

BACKGROUND: Entering higher education is a time of transition that coincides with the typical age of onset of serious mental illness. Awareness of the distinguishing characteristics of students with mental illness who die by suicide may inform clinical management. AIM: We aimed to compare the characteristics of mental health patients who died by suicide as students with other young people who died by suicide. METHOD: UK data were analyzed for individuals aged 18-35 years in contact with mental health services who died by suicide from 1997 to 2012. Univariate analyses examined the sociodemographic, behavioral, and clinical features of those who died as students. Backward stepwise regression analysis identified factors independently associated with student deaths. RESULTS: In all, 214 university students died by suicide within 12 months of mental health service contact. Factors associated with student deaths were: being younger, female, from an ethnic minority group, and a primary diagnosis of affective disorder. Medication nonadherence was less likely to be associated with student deaths. CONCLUSION: Deaths by suicide are split almost equally between male and female students, unlike the predominance of male suicide in the general population. There are clear differences in the characteristics of the student and nonstudent groups, although causation could not be established.

The timing of general population and patient suicide in England, 1997-2012.

BACKGROUND: There have been conflicting findings on temporal variation in suicide risk and few have examined the phenomenon in clinical populations. The study investigated seasonal and other temporal patterns using national data. METHODS: Data on 73,591 general population and 19,318 patient suicide deaths in England between 1997 and 2012 were collected through the National Confidential Inquiry into Suicide examining suicide rates in relation to month of the year, day of the week, and individual days of national or religious significance. RESULTS: Suicide incidence fell over successive months of the year and there was evidence of an overall spring peak. Monday was associated with the highest suicide rates and in the patient population this effect appeared to be more pronounced in those aged over 50 or those who lived alone. Suicide risk was significantly lower during Christmas, particularly for women. There was a peak in suicide on New Year's Day in the general population. Other 'special days' were not associated with a change in suicide incidence. LIMITATIONS: We were limited to identifying associations between the variables investigated and were unable to explore causal mechanisms. We did not carry out comprehensive multi-variable adjustment in our regression models. CONCLUSIONS: There is substantial seasonal and temporal variation in suicide deaths, and there appears to be some evidence in the clinical as well as the general population in England. Clinical services should be aware of the risk of suicide just after the weekend, especially in people who live alone, and the potential need for closer supervision during this period.

Clinical management following self-harm in a UK-wide primary care cohort.

BACKGROUND: Little is known about the clinical management of patients in primary care following self-harm. METHODS: A descriptive cohort study using data from 684 UK general practices that contributed to the Clinical Practice Research Datalink (CPRD) during 2001-2013. We identified 49,970 patients with a self-harm episode, 41,500 of whom had one complete year of follow-up. RESULTS: Among those with complete follow-up, 26,065 (62.8%, 62.3-63.3) were prescribed psychotropic medication and 6318 (15.2%, 14.9-15.6) were referred to mental health services; 4105 (9.9%, CI 9.6-10.2) were medicated without an antecedent psychiatric diagnosis or referral, and 4,506 (10.9%, CI 10.6-11.2) had a diagnosis but were not subsequently medicated or referred. Patients registered at practices in the most deprived localities were 27.1% (CI 21.5-32.2) less likely to be referred than those in the least deprived. Despite a specifically flagged NICE 'Do not do' recommendation in 2011 against prescribing tricyclic antidepressants following self-harm because of their potentially lethal toxicity in overdose, 8.8% (CI 7.8-9.8) of individuals were issued a prescription in the subsequent year. The percentage prescribed Citalopram, an SSRI antidepressant with higher toxicity in overdose, fell sharply during 2012/2013 in the aftermath of a Medicines and Healthcare products Regulatory Agency (MHRA) safety alert issued in 2011. CONCLUSIONS: A relatively small percentage of these vulnerable patients are referred to mental health services, and reduced likelihood of referral in more deprived localities reflects a marked health inequality. National clinical guidelines have not yet been effective in reducing rates of tricyclic antidepressant prescribing for this high-risk group.

Mental health service changes, organisational factors, and patient suicide in England in 1997-2012: a before-and-after study.

BACKGROUND: Research into which aspects of service provision in mental health are most effective in preventing suicide is sparse. We examined the association between service changes, organisational factors, and suicide rates in a national sample. METHODS: We did a before-and-after analysis of service delivery data and an ecological analysis of organisational characteristics, in relation to suicide rates, in providers of mental health care in England. We also investigated whether the effect of service changes varied according to markers of organisational functioning. FINDINGS: Overall, 19 248 individuals who died by suicide within 12 months of contact with mental health services were included (1997-2012). Various service changes related to ward safety, improved community services, staff training, and implementation of policy and guidance were associated with a lower suicide rate after the introduction of these changes (incidence rate ratios ranged from 0·71 to 0·79, p<0·0001). Some wider organisational factors, such as non-medical staff turnover (Spearman's r=0·34, p=0·01) and incident reporting (0·46, 0·0004), were also related to suicide rates but others, such as staff sickness (-0·12, 0·37) and patient satisfaction (-0·06, 0·64), were not. Service changes had more effect in organisations that had low rates of staff turnover but high rates of overall event reporting. INTERPRETATION: Aspects of mental health service provision might have an effect on suicide rates in clinical populations but the wider organisational context in which service changes are made are likely to be important too. System-wide change implemented across the patient care pathway could be a key strategy for improving patient safety in mental health care. FUNDING: The Healthcare Quality Improvement Partnership commissions the Mental Health Clinical Outcome Review Programme, National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, on behalf of NHS England, NHS Wales, the Scottish Government Health and Social Care Directorate, the Northern Ireland Department of Health, Social Services and Public Safety, and the States of Jersey and Guernsey.

Self-harm in bipolar disorder: findings from a prospective clinical database.

BACKGROUND: People with bipolar disorder may be at increased risk of suicidal behaviour but there are few prospective studies of self-harm in this group. Our aim was to describe the characteristics and outcome (in terms of repetition) for individuals with bipolar disorder who presented to hospital following self-harm. METHOD: A nested case-control study was carried out using a large prospective self-harm database (1997-2010) in Manchester, UK. Characteristics of bipolar cases and non-bipolar controls were compared using conditional logistic regression, and outcomes were assessed via survival analyses. RESULTS: Bipolar cases (n=103) were more likely to repeat self-harm than controls (n=515): proportion with at least one repeat episode 58% vs. 25%, HR 3.08 (95% CI; 2.2-4.18). Previous self-harm, unemployment, contact with psychiatric services and sleep disturbance were all more common in cases than controls. Even after adjustment for known risk factors, the risk of repetition remained higher in the bipolar group (adjusted HR 1.68; 95% CI; 1.10-2.56). LIMITATIONS: The study covers cases from hospital sites in Manchester, UK, and therefore only includes self-harm that was serious enough to present at hospital emergency departments. CONCLUSION: People with bipolar disorder who self-harm have a higher risk of repetition than people who self-harm more generally. Adjusting for some known risk factors moderated, but did not abolish, this finding. Other factors, such as impulsivity, may also be important.