Children and young people's beliefs about mental health and illness in Indonesia: A qualitative study informed by the Common Sense Model of Self-Regulation.

BACKGROUND: Mental illness is a leading cause of disease burden amongst children and young people (CYP). This is exacerbated in low- and middle-income (LMIC) countries which often have embryonic care structures. Understanding and targeting illness beliefs is a potentially efficacious way of optimising the development of health prevention interventions. These beliefs remain relatively underexplored in CYP in LMIC contexts. Aim: To develop an in-depth understanding of CYPs beliefs about mental health and illness in Indonesia. METHODS AND FINDINGS: Semi-structured interviews (n = 43) combined with photo elicitation methodology were undertaken with CYP aged 11-15 from Java, Indonesia. Our sample comprised those living with (n = 19) and without (n = 24) high prevalence mental health conditions, specifically anxiety or depression. Data were analysed using framework analysis, informed by the Common Sense Model of Self-Regulation of Health and Illness. Positive mental health and illness were dichotomised in accounts with mental health typically characterised as an absence of mental disturbance. This contributed to attributions of abnormality and the marginalisation of those with mental illness. Mental illness was conceptualised as a single entity, commonly arising from individual failings. This prompted feelings of self-stigma in those with lived experience of mental illness. Analysis identified marked differences in the perceived time dimensions of positive mental health and illness with mental illness conceived as less transient than episodes of positive mental health. Illness beliefs appeared relatively consistent across the two groups of CYP although some nuanced differences were identified. CYP with anxiety and depression were less likely to believe that mental illness could be diagnosed visually, more likely to uphold multiple causal factors and endorse the potential efficacy of professional input. CONCLUSIONS: Public health interventions to increase understanding may be necessary to develop healthcare systems to reduce treatment barriers, optimise return on investment and enhance population health effect.

Mental health literacy amongst children with common mental health problems and their parents in Java, Indonesia: a qualitative study.

Background: Optimising mental health literacy (MHL) at the individual and population level can be an effective mental health improvement and prevention tool. However, concepts of MHL are largely based on evidence from high-income countries. Little is known about the manifestation and role of MHL in countries where collectivist health and social cultures are dominant. Aim: This study aimed to examine the MHL of Indonesian children and young people (CYP) with experience of common mental health problems and their parents. Methods: Semi-structured interviews with 40 participants (19 CYP aged 11-15 with experience of common mental health problems and 21 parents) from three areas of Java, Indonesia. Data were analysed using framework analysis, informed by Jorm's 1997 Mental Health Literacy Framework. Results: Parents and CYP demonstrated relatively low levels of MHL defined from a conventional perspective. Religiosity and spirituality were salient in participants' accounts, particularly parents, as were narratives about personal responsibility. These beliefs appeared to contribute to a high level of self-blame for mental illness, self-reliance for symptom management, the foregrounding of support from spiritual/traditional healers and a reduced propensity to access professional help. CYP were heavily reliant on family support, but parents often felt they were not best placed to communicate with their children about mental health. Providing trusted, technology-based sources of mental health information were advocated by CYP. Conclusion: Robust efforts are needed to improve MHL in low- and middle-income countries drawing on culturally appropriate approaches to reduce stigma and optimise timely, effective help-seeking for CYP. Enhancing parental and family level literacy may be efficacious, especially when combined with mechanisms to facilitate open communication, as may the development of standalone interventions directly developed to reach younger generations. Future research may usefully establish the comparative efficacy and acceptability of these different approaches.

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 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.

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.

Suicide after absconding from inpatient care in England: an exploration of mental health professionals' experiences.

BACKGROUND: Absconding from inpatient care is associated with suicide risk in psychiatric populations. However, little is known about the real world context of suicide after absconding from a psychiatric ward or the experiences of clinical staff caring for these patients. AIMS: To identify the characteristics of inpatients who died by suicide after absconding and to explore these and further key issues related to suicide risk from the perspective of clinical staff. METHODS: A mixed-methods study using quantitative data of all patient suicides in England between 1997 and 2011 and a thematic analysis of semi-structured interviews with 21 clinical staff. RESULTS: Four themes were identified as areas of concern for clinicians: problems with ward design, staffing problems, difficulties in assessing risk, and patient specific factors. CONCLUSIONS: Results suggest that inpatients who died by suicide after absconding may have more complex and severe illness along with difficult life events, such as homelessness. Closer monitoring of inpatients and access points, and improved risk assessments are important to reduce suicide in this patient group.

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.

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.

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.

Investigating the feasibility and acceptability of a cognitive behavioural suicide prevention therapy for people in acute psychiatric wards (the 'INSITE' trial): study protocol for a randomised controlled trial.

BACKGROUND: Suicide is a major cause of preventable death, and suicidal behaviour is prevalent in acute psychiatric wards. People admitted to acute psychiatric wards often experience repeated episodes of suicidal behaviour, causing great distress and heavy use of NHS services. There is little research investigating effective psychological treatments for suicidal patients in inpatient settings although previous research has found support for psychological therapies which specifically target suicidal behaviour. This paper describes the protocol of a single blind RCT to investigate the acceptability and feasibility of a cognitive behavioural intervention targeting suicidality (CBSP) for suicidal people in acute psychiatric wards. METHODS/DESIGN: A single blind RCT comparing treatment as usual (TAU) to TAU plus Cognitive Behavioural Suicide Prevention (CBSP) therapy (TAU + CBSP). Sixty participants (aged 18-65 years) who are suicidal, or have been within the past 3 months, will be recruited from NHS trusts in the North West of England. Our primary objective is to determine whether CBSP is feasible, acceptable and efficacious when compared to patients who receive TAU alone. Secondary aims are the impact of CBSP on suicidal thinking, behaviours, functioning, quality of life, service use and psychological factors associated with suicide. Assessments take place at baseline, 6 weeks and 6 months (end of treatment). The analysis will report on the feasibility and acceptability of CBSP. Qualitative data from staff and service users will inform feasibility and acceptability data. DISCUSSION: Psychiatric inpatients are a high-risk group and the use of psychological therapies in these settings is rare and requires evaluation. This study is essential to investigate the unique contextual challenges involved in delivering psychological therapy to suicidal inpatients and to identify any necessary modifications required within inpatient settings. The findings will inform a larger, definitive trial. TRIAL REGISTRATION: 15 March 2012, PB-PG-1111-26026, NIHR ISRCTN17890126 .

Assessment and management of suicide risk in primary care.

BACKGROUND: Risk assessment and management of suicidal patients is emphasized as a key component of care in specialist mental health services, but these issues are relatively unexplored in primary care services. AIMS: To examine risk assessment and management in primary and secondary care in a clinical sample of individuals who were in contact with mental health services and died by suicide. METHOD: Data collection from clinical proformas, case records, and semistructured face-to-face interviews with general practitioners. RESULTS: Primary and secondary care data were available for 198 of the 336 cases (59%). The overall agreement in the rating of risk between services was poor (overall κ = .127, p = .10). Depression, care setting (after discharge), suicidal ideation at last contact, and a history of self-harm were associated with a rating of higher risk. Suicide prevention policies were available in 25% of primary care practices, and 33% of staff received training in suicide risk assessments. CONCLUSION: Risk is difficult to predict, but the variation in risk assessment between professional groups may reflect poor communication. Further research is required to understand this. There appears to be a relative lack of suicide risk assessment training in primary care.

Safety of patients under the care of crisis resolution home treatment services in England: a retrospective analysis of suicide trends from 2003 to 2011.

BACKGROUND: Community care provided by crisis resolution home treatment teams is used increasingly as an alternative to admission to psychiatric wards. No systematic analysis has been done of the safety of these teams in terms of rates of suicide. We aimed to compare the rate and number of suicides among patients under the care of crisis resolution home treatment teams with those of psychiatric inpatients. We also assessed the clinical features of individuals who died by suicide in both home and hospital settings. METHODS: We did a retrospective longitudinal analysis between 2003 and 2011 of all adults (aged 18 years or older) treated by the National Health Service in England who died by suicide while under the care of crisis resolution home treatment services or as a psychiatric inpatient. We obtained data from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness and from the Mental Health Minimum Dataset. FINDINGS: 1256 deaths by suicide (12% of all patient suicides) were recorded among patients cared for under crisis resolution home treatment teams, an average of 140 deaths per year. Different denominators meant that direct comparison between groups was difficult, but the average rate of suicide under crisis resolution home treatment services (14·6 per 10 000 episodes under crisis care) seemed higher than the average rate of suicide among psychiatric inpatients (8·8 per 10 000 admissions). The number of suicides in patients under the care of crisis resolution home treatment teams increased from an average of 80 per year (in 2003 and 2004) to 163 per year (in 2010 and 2011) and were twice as frequent as inpatient suicides in the last few years of the study. However, because of the growing number of patients under the care of crisis resolution home treatment teams, the average rate of suicide fell by 18% between the first and last 2 years of the study. 548 (44%) patients who died by suicide under the care of crisis resolution home treatment teams lived alone and 594 (49%) had had a recent adverse life event. In a third of patients (n=428) under the care of crisis resolution home treatment teams, suicide happened within 3 months of discharge from psychiatric inpatient care. INTERPRETATION: Although the number of suicides under the care of crisis resolution home treatment teams has risen since 2003, the rate has fallen. However, suicide rates remain high compared with the inpatient setting, and safety of individuals cared for by crisis resolution home treatment teams should be a priority for mental health services. For some vulnerable people who live alone or have adverse life circumstances, crisis resolution home treatment might not be the most appropriate care setting. Use of crisis resolution home treatment teams to facilitate early discharge could present a risk to some patients, which should be investigated further. FUNDING: Healthcare Quality Improvement Partnership.

Suicide and accidental deaths in children and adolescents in England and Wales, 2001-2010.

OBJECTIVES: To investigate the impact of narrative verdicts on suicide statistics among 10-19-year-olds; to identify the number and rate of suicide and accidental deaths, particularly in 10-14-year-olds. DESIGN: National cohort study. SETTING: England and Wales. METHODS: Mid-year population estimates from the Office for National Statistics (ONS) were used to calculate rates per 100,000 population for suicide (undetermined and suicide verdicts) and accidental deaths (poisoning, hanging) for those aged 10-14 and 15-19. Trends in rates over time (2001-2010) were investigated using Poisson regression. Interaction tests were carried out to determine differences in trends between the two time periods (2001-2005 and 2006-2010). RESULTS: There were 1523 suicides (2.25/100,000). Suicide rates were highest in those aged 15-19 years (4.04/100,000) and in males (3.14/100,000). Between 2001 and 2010, rates significantly decreased among those aged 15-19 years (incidence rate-ratio (IRR): 0.95; 95% CI 0.93 to 0.97), with no change in rates of accidental deaths (IRR: 1.01, 95% CI 0.95 to 1.07). However, there was a significant interaction between the two time periods for accidental poisonings (2001-2005: IRR: 0.79 (95% CI 0.69 to 0.91); 2006-2010: IRR: 1.01 (95% CI 0.89 to 1.15), interaction p=0.012) and accidental hangings (2001-2005: IRR: 0.93 (95% CI 0.76 to 1.14); 2006-2010: IRR: 1.25 (95% CI 1.04 to 1.49), interaction=0.01) Undetermined deaths significantly decreased among females aged 15-19 yeras (IRR: 0.93; 95% CI 0.88 to 0.98). There were no significant trends among 10-14-year-olds. CONCLUSIONS: Rates of suicide are higher among older adolescents and males. There was a significant fall in suicide rates in males aged 15-19 years that was not accounted for by changes in rates of accidental death. The absence of a significant trend in suicide or accidental deaths in those aged 10-14 years may have been the result of small numbers. However, monitoring should continue to identify longitudinal trends in all young people.

Suicide within two weeks of discharge from psychiatric inpatient care: a case-control study.

OBJECTIVE: Suicide risk after discharge from psychiatric inpatient care is high, particularly in the first few weeks. The aim of the study was to identify risk factors and protective factors (that is, factors associated with a reduced risk of suicide), including variation in health care received, for suicide among patients in the two-week postdischarge period. METHODS: This was a national population-based retrospective case-control study of 100 psychiatric patients in England (2004-2006), age 18-65, who died by suicide within two weeks of hospital discharge. These patients were matched on discharge date with 100 living control group patients. RESULTS: Fifty-five percent of suicides occurred within a week of discharge, 49% of whom died before their first follow-up appointment. Conditional logistic regression analyses indicated that recent adverse life events and a short (less than one week) final admission were independently associated with postdischarge suicide, as were older age and comorbid psychiatric disorders. Receiving enhanced aftercare (under the Care Programme Approach) was protective of suicide. CONCLUSIONS: Discharged patients viewed as being at high risk of suicide require immediate community follow-up. Mental health services should be mindful of discharging patients after a short admission. The potential role of detrimental life experiences indicates that mental health clinicians need to be aware of the circumstances into which patients are being discharged. Use of enhanced levels of care, such as that offered by the Care Programme Approach, may play a strong role in preventing suicide within two weeks of discharge.

Why does Scotland have a higher suicide rate than England? An area-level investigation of health and social factors.

BACKGROUND: Up until the mid-late 2000s, the national suicide rate in Scotland was the highest among all the UK countries, but the reasons for this phenomenon are poorly understood. METHODS: In a multilevel study of suicide risk in Scotland and England during 2001-2006, the authors examined a range of social, cultural and health-related factors at small area level: postcode sector and Health Board in Scotland and ward and Primary Care Organisation in England. RESULTS: Scotland's national suicide rate was 79% higher than in England (rate ratio 1.79, 95% CI 1.62 to 1.98), with younger male and female Scots aged 15-44 years having double the risk compared with their English peers. Overall, 57% of the excess suicide risk in Scotland was explained by a range of area-level measures, including prescriptions for psychotropic drugs, alcohol and drug use, socioeconomic deprivation, social fragmentation, and other health-related indices. The use of psychotropic drugs, acting as a proxy measure for mental ill health, was the variable most strongly associated with the between-country differences in suicide risk. Alcohol misuse also made an important contribution to the differentials. Overall, the contribution of socioeconomic deprivation and social fragmentation was relatively small. CONCLUSIONS: Any attempt to reverse the divergent trend in suicide between Scotland and England will require initiatives to prevent and treat mental ill health and to tackle alcohol and drug misuse. Differences in prescribing rates, however, may also be explained by differences in illness behaviour or the availability of psychosocial interventions, and addressing these may also reduce Scotland's excess risk.

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

BACKGROUND: Around a quarter of in-patient suicides occur within the first week of admission to psychiatric in-patient care. Little is known on the factors associated with suicide during this critical time. We aimed to identify risk factors for suicide among in-patients within the first week of admission. METHODS: A national population-based case-control study of 107 current psychiatric in-patients in England who died by suicide within a week of admission, matched on admission date with 107 living controls. RESULTS: Forty-two (40%) suicide cases died within the first 3 day of admission. A fifth of all suicides were on authorised leave at the time of death, but 34% were off the ward without staff agreement compared to only 1% of controls. Independent risk factors for suicide included previous self-harm, recent adverse life events, and a short (<12 months) duration of illness. LIMITATIONS: This is a retrospective study, using clinical data mainly collected from case records. Clinicians were not blind to case/control status. CONCLUSIONS: The first few days of admission should be recognised as the period of highest risk. Careful risk evaluation is needed at this time, particularly in those with recent illness onset or previous suicide attempts. Knowledge of life events experienced before admission should be incorporated into risk assessments. Improvements to the ward environment to lessen the distress of an admission may be an important preventative measure. Protocols may require adapting to improve the safety of those on agreed leave, and prevent absconding through increased vigilance and closer observation of ward exits.

Ligature points and ligature types used by psychiatric inpatients who die by hanging: a national study.

BACKGROUND: Approximately three-quarters of patients who die by suicide on psychiatric wards do so by hanging/strangulation. Increased awareness of the methods used by these patients may benefit prevention strategies in mental health services. AIMS: To describe the ligature points and ligatures used in ward hangings; to identify any trends over time in ligature points and ligatures used; and to compare these patient characteristics with other inpatient suicides. METHODS: A national clinical survey of suicide cases in recent (<1 year) contact with mental health services in England and Wales (1999-2007). RESULTS: Of the 448 suicides that occured on psychiatric wards, 77% were by hanging. The number of hanging cases, however, has fallen by 74% since 1999. The most common ligature points and ligatures were doors, hooks/handles, windows, and belts or sheets/towels, respectively. Use of shoelaces, doors, and windows increased over time. These patient suicides had had high rates of self-harm, alcohol/drug misuse, and were more likely than other cases to have died early in admission and been formally detained for treatment. CONCLUSIONS: Despite the decrease in inpatient suicides by hanging, regular reviews of ward structures are needed, particularly as ligatures and ligature points change over time. Improving the ward environment to engage patients, especially early in admission, may also contribute to reducing risk.

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.

Trends in national suicide rates for Scotland and for England & Wales, 1960-2008.

BACKGROUND: Suicide rates in Scotland have increased markedly relative to those in England in recent decades. AIMS: To compare changing patterns of suicide risk in Scotland with those in England & Wales, 1960-2008. METHOD: For Scotland and for England & Wales separately, we obtained national data on suicide counts and population estimates. Gender-specific, directly age-standardised rates were calculated. RESULTS: We identified three distinct temporal phases: 1960-1967, when suicide rates in England & Wales were initially higher than in Scotland, but then converged; 1968-1991, when male suicide rates in Scotland rose slightly faster than in England & Wales; and 1992-2008, when there was a marked divergence in national trends. Much of the recent divergence in rates is attributable to the rise in suicide among young men and deaths by hanging in Scotland. Introduction of the 'undetermined intent' category in 1968 had a significant impact on suicide statistics across Great Britain, but especially so in Scotland. CONCLUSIONS: Differences in temporal patterns in suicide risk between the countries are complex. Reversal of the divergent trends may require a change in the perception of hanging as a 'painless' method of suicide.

Suicide and mental illness: a clinical review of 15 years findings from the UK National Confidential Inquiry into Suicide.

INTRODUCTION: Suicide risk is most commonly associated with mental illness. In particular, suicide in people under mental health care presents distinct patterns of risk and opportunities for prevention due to their close proximity to specialist care. SOURCES OF DATA: The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (Inquiry) is a unique UK-wide national database of all suicide cases in contact with mental health services in the 12 months preceding suicide. This review presents Inquiry findings from the beginning of the Inquiry in 1996 up to the present (2011) (15 years). AREAS OF AGREEMENT: Suicide varies substantially by socio-demographic (age, gender) and clinical features (e.g. diagnosis; care variables). Effective suicide prevention initiatives should incorporate research findings to inform clinical practice and policy. AREAS OF CONTROVERSY: Risk assessment remains one of the most difficult areas of clinical practice and management although all areas of clinical practice, research and policy development would benefit from continued high-quality studies. GROWING POINTS: The Inquiry work has positively influenced mental health practice and policy in the UK. These changes include: falling suicide rates in mental health patients, informing suicide prevention strategies and developing safety checklists for mental health services. AREAS TIMELY FOR DEVELOPING RESEARCH: Investigating suicide in non-mental health settings, investigating suicide following different treatment services and investigating models of service delivery could usefully inform future directions for improving patient safety.