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.

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.

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.

National study of suicide method in violent criminal offenders.

BACKGROUND: Gaining a greater knowledge of the mechanisms and means by which violent offenders die by suicide can inform tailored preventive strategies. METHODS: Using interlinked national Danish registry data we constructed a nested case-control study dataset of all adult suicides during 1994-2006: N=9708 cases and N=188,134 age and gender matched living controls. Completely ascertained International Classification of Diseases 10th revision cause-specific mortality codes were examined, with all criminal charges since 1980, and covariate information on psychiatric treatment and socio-demographics. Self-poisonings were classified as 'nonviolent' suicide and all other methods as being 'violent' ones. RESULTS: Compared with the general population, risk among male and female violent offenders was strongly and significantly elevated for suicide by either a violent or a nonviolent method, although the relative risk was greater for nonviolent suicide. These patterns were also observed among nonviolent offenders, albeit with smaller effect sizes. Risk was especially raised for self-poisoning with narcotics & hallucinogens. We could only examine the full range of suicide methods in male violent offenders. In these men, hanging was the most frequently used method, although risk was markedly and significantly elevated virtually across the entire range of regularly used suicide methods. LIMITATIONS: We lacked sufficient statistical power for undertaking a detailed profiling of specific suicide methods among female violent offenders. CONCLUSIONS: Our findings indicate that comprehensive and broadly-based preventive approaches are needed for tackling the markedly raised risk of suicide by both violent and nonviolent means in this population. Their high relative risk for self-poisoning by illicit or illegal drugs underlines the importance of access to means and of prevailing subculture.

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.

Filicide in offspring of parents with severe psychiatric disorders: a population-based cohort study of child homicide.

OBJECTIVE: Although rare in absolute terms, risk of homicide is markedly elevated among children of parents with mental disorders. Our aims were to examine risk of child homicide if 1 or both parents had a psychiatric history, to compare effects by parental sex and diagnostic group, and to assess likelihood of child homicide being perpetrated by parents according to their psychiatric history. METHOD: A prospective, register-based cohort study using the entire Danish population born between January 1, 1973, and January 1, 2007, was conducted. Follow-up of the cohort members began on their date of birth and ended on January 1, 2007; their 18th birthday; their date of death; or their date of emigration, whichever came first. We used the Danish national registers from 1973 to 2007 to study homicide risk between children whose parents were previously admitted to a psychiatric hospital, including diagnosis-specific analyses, versus their unexposed counterparts. In addition, we used police records during 2000 to 2005 to examine whether or not 1 of the parents was the perpetrator. Rates of homicide were analyzed using survival analysis. RESULTS: Children of parents previously admitted to a psychiatric hospital had an overall higher risk of being homicide victims (MRR = 8.94; 95% CI, 6.56-12.18). The risk differed according to parental sex and psychiatric diagnosis (ICD-8 and ICD-10 criteria). The absolute risk of homicide was 0.009% if neither parent had been admitted before the birth of their child and 0.051% if 1 of the parents had previously been admitted. During 2000 to 2005, 88% of the child homicide cases were filicide victims. This percentage was not significantly different for parents with a previous psychiatric admission versus those without such a history. CONCLUSIONS: In the large majority of Danish child-homicide cases, a parent was the perpetrator, regardless of whether there had been parental admission to a psychiatric hospital. Children of parents previously admitted had a higher risk of being homicide victims, and risks were especially high in young children whose mothers were hospitalized with affective disorders or schizophrenia. However, the relative risks presented in the current study are based on extremely rare events, and the overwhelming majority of children whose parents have a psychiatric history do not become homicide victims.

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.

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.

Risk of stillbirth and neonatal death linked with maternal mental illness: a national cohort study.

BACKGROUND: Babies of mothers with psychotic disorders are known to have higher rates of poor obstetric outcome, including higher mortality rates. OBJECTIVE: To estimate risks of stillbirth and neonatal death by specific causes in babies of mothers with histories of severe mental illness, relative to the general population. METHODS: A cohort of 1.45 million live births and 7021 stillbirths during 1973-98 was identified from Danish national registers. These registers were linked to identify babies who were stillborn or died neonatally after exposure to maternal psychiatric illness. RESULTS: Risks of stillbirth and neonatal death were raised for virtually all causes of death for all of the maternal psychiatric diagnostic categories. For most causes of death, offspring of women with schizophrenia and related disorders had no greater risks of stillbirth or neonatal death than offspring of women with other maternal psychiatric disorders (eg, neonatal death (NND) due to immaturity: relative risks (95% CI) schizophrenia and related disorders: 1.1 (0.4 to 3.5), affective disorders: 2.0 (1.2 to 3.5)). There was a greater risk of fatal congenital malformation associated with a history of maternal affective disorder (stillbirth 2.4 (1.1 to 5.1), NND 2.1 (1.4 to 3.3)) or schizophrenia and related disorders (stillbirth 2.4 (0.8 to 7.6), NND 2.2 (1.1 to 4.1)) than with maternal alcohol/drug-related disorders (stillbirth 1.2 (0.4 to 3.8), NND 1.1 (0.6 to 2.2)). CONCLUSIONS: Higher risk of perinatal loss may be linked to factors associated with maternal psychiatric illness in general, such as insufficient attendance for antenatal care and unhealthy lifestyles rather than the maternal mental illness itself.

Parental mental illness and fatal birth defects in a national birth cohort.

BACKGROUND: Few large studies describe links between maternal mental illness and risk of major birth defect in offspring. Evidence is sparser still for how effects vary between maternal diagnoses and no previous study has assessed risk with paternal illnesses. METHOD: A population-based birth cohort was created by linking Danish national registers. We identified all singleton live births during 1973-1998 (n=1.45 m), all parental psychiatric admissions from 1969 onwards, and all fatal birth defects until 1 January 1999. Linkage and case ascertainment were almost complete. Relative risks were estimated using Poisson regression. RESULTS: Risk of fatal birth defect was elevated in relation to history of any maternal admission and also with affective disorders specifically, although the strongest effect found was with maternal schizophrenia. The rate was more than doubled in this group compared to the general population [relative risk (RR) 2.34, 95% confidence interval (CI) 1.45-3.77], which also represented a significant excess risk compared with all other admitted maternal disorders (p=0.018). Risk of death from causes other than birth defect was no higher with schizophrenia than with other maternal conditions. There was no elevation in risk of fatal birth defect if the father was admitted with schizophrenia or any other psychiatric diagnosis. CONCLUSIONS: There are many possible explanations for a higher risk of fatal birth defect with maternal schizophrenia and affective disorder. These include genetic effects directly linked with maternal illness, lifestyle factors (diet, smoking, alcohol and drugs), poor antenatal care, psychotropic medication toxicity, and gene-environment interactions. Further research is needed to elucidate the causal mechanisms.

Predictors of parenting outcome in women with psychotic disorders discharged from mother and baby units.

OBJECTIVE: To compare the social and clinical characteristics of mothers with psychotic disorders with parenting difficulties, with mothers with no significant parenting problems. METHOD: Descriptive and case-control study. RESULTS: Over half of the women with psychotic disorders admitted to psychiatric mother and baby units had a good outcome at the time of discharge--70% did not need social services supervision, and had no significant parenting problem as judged by clinical staff. Diagnosis was independently associated with all measures of poor parenting; compared with a diagnosis of psychotic depression, a diagnosis of schizophrenia was highly significantly associated with social services supervision [adjusted odds ratio (OR) 25.7; 95% CI 5.97, 111.05], and staff rated problems with emotional responsiveness (adjusted OR 3.39;95% CI 1.42, 8.08), practical baby care (adjusted OR 6.07; 95% CI 2.12, 17.39), and perceived risk of harm to baby (adjusted OR 7.81; 95% CI. 2, 30.53). Low social class and psychiatric illness in the partner were also significantly associated with poor parenting outcomes, including social services supervision (adjusted OR 3.88; 95% CI 2.07, 7.25 and 4.23; 95% CI 2.1, 8.55, respectively). CONCLUSIONS: Although these associations do not demonstrate causality, these findings suggest preventative interventions targeting socio-economic difficulties, early treatment of psychosis, and detection and treatment of psychiatric problems in the partner may be helpful in improving parenting outcomes in these vulnerable families.

Defining the needs of patients with intellectual disabilities in the high security psychiatric hospitals in England.

BACKGROUND: Previous studies have suggested that a substantial proportion of the patients with intellectual disabilities (ID) in the high security psychiatric hospitals (HSPHs) should be transferred to more appropriate services to cater for their specific needs in the longer term. METHOD: The individual and placement needs of high secure psychiatric patients detained under the legal category of mental impairment or severe mental impairment were assessed in a cross-sectional survey. RESULTS: Patients had a large number of needs (on average 10.8), about a third of which were rated as unmet and therefore represented significant continuing problems. Approximately one-third of the sample could be moved out of HSPHs if appropriate alternatives were available. Factors associated with the continued need for high security included higher treatment and security needs, younger age, recent violent conduct and their index offence profile. CONCLUSIONS: High security services are still required for a number of patients with ID. New and existing services need to be configured to meet specific profiles of need and provide long-term rehabilitation and specialist care. DECLARATION OF INTEREST: This was part of a larger project funded by grants from the High Security Psychiatric Services Commissioning Board and Department of Health.

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.

A national audit of joint mother and baby admissions to UK psychiatric hospitals: an overview of findings.

The Marcé Clinical Audit is an ongoing data collection exercise that gathers socio-demographic and clinical information about mothers and their infants, admitted jointly to specialist units in UK psychiatric hospitals. The maternal and parenting outcomes, in particular of mothers with schizophrenia and mothers who harm themselves and/or their infants, were determined and analysed. The majority of women had a primary diagnosis of either depression (43%) or schizophrenia (21%). Mothers with schizophrenia were three times more likely to experience a poor outcome than non-schizophrenic mothers, were more likely to be separated from their infant at discharge and were perceived, by staff, to be at greater risk of harming their infant. They were, however, shown to be no more likely to cause actual harm to their infant, or themselves, than non-schizophrenic mothers.

Life events preceding suicide by young people.

BACKGROUND: Life events are often reported to precede suicide. This paper aims to determine the frequency, timing and type of life events preceding suicide by young people and those with and without a mental illness. METHOD: Informants, usually family members, were interviewed for a sample of young (less than 35 years) suicides. Information was recorded on events occurring in the 6 months before death. Equivalent information was obtained for living controls who had been matched for age and gender and obtained through the general practices of the suicides. RESULTS: Suicide was associated with life events in the previous 3 months, and particularly in the previous week. Specifically, interpersonal and forensic (being arrested, charged or sentenced) events distinguished suicides and controls. The number of life events in the different time periods under study did not distinguish suicides with and without severe mental illness, although more suicides without a severe mental illness had a reported life event in the week before their death. CONCLUSIONS: Adverse life events frequently precede suicide in young people with and without severe mental illness. However, recent life events may have a lesser causal role in those with severe mental illness. Clinical and health promotion measures to improve the way that young people cope with interpersonal problems and other crises may be an important part of any suicide prevention strategy.

Health of children considered for adoption.

Children in the 'care' system are known to have poor health. Although health services can respond to and deal with health problems, it is parents, foster parents and social workers who recognize problems, seek advice and keep follow-up appointments. Many health needs remain unmet in such children. This short paper from a deprived area in north-east England shows that once a decision is made to proceed to adoption, the stable and consistent care that can then be provided meets the increased health needs that such children have.