Contacts with primary and secondary healthcare before suicide by those under the care of mental health services: case-control, whole-population-based study using person-level linked routine data in Wales, UK during 2000-2015.

BACKGROUND: People under the care of mental health services are at increased risk of suicide. Existing studies are small in scale and lack comparisons. AIMS: To identify opportunities for suicide prevention and underpinning data enhancement in people with recent contact with mental health services. METHOD: This population-based study includes people who died by suicide in the year following a mental health services contact in Wales, 2001-2015 (cases), paired with similar patients who did not die by suicide (controls). We linked the National Confidential Inquiry into Suicide and Safety in Mental Health and the Suicide Information Database - Cymru with primary and secondary healthcare records. We present results of conditional logistic regression. RESULTS: We matched 1031 cases with 5155 controls. In the year before their death, 98.3% of cases were in contact with healthcare services, and 28.5% presented with self-harm. Cases had more emergency department contacts (odds ratio 2.4, 95% CI 2.1-2.7) and emergency hospital admissions (odds ratio 1.5, 95% CI 1.4-1.7), but fewer primary care contacts (odds ratio 0.7, 95% CI 0.6-0.9) and out-patient appointments (odds ratio 0.2, 95% CI 0.2-0.3) than controls. Odds ratios were larger in females than males for injury and poisoning (odds ratio: 3.3 (95% CI 2.5-4.5) v. 2.6 (95% CI 2.1-3.1)). CONCLUSIONS: We may be missing existing opportunities to intervene, particularly in emergency departments and hospital admissions with self-harm presentations and with unattributed self-harm, especially in females. Prevention efforts should focus on strengthening routine care contacts, responding to emergency contacts and better self-harm care. There are benefits to enhancing clinical audit systems with routinely collected data.

Substance use and self-poisoning in schizophrenia: 11-year findings from a national clinical survey of suicide in mental health patients in England.

Suicide is the leading cause of unnatural death among people with schizophrenia. Substance use is a highly prevalent comorbid feature of schizophrenia and a modifiable risk factor for suicide. However, no studies have examined changes in the frequency of substance use or self-poisoning in those who died by suicide over time. Knowing this could support more tailored approaches to reducing specific risk factors and access to means in those with schizophrenia who are at risk of suicide. We conducted an 11-year observational study on a clinical survey of people with schizophrenia in England who died by suicide within 12 months of contact with mental health services between 2010 and 2020 (n = 2718). Overall, alcohol, cannabis and stimulants were the most frequently reported substances. The odds of lifetime use significantly increased over time for cannabis, stimulants, heroin, and benzodiazepines. There were differences in socio-demographic, behavioural and clinical factors between those with recent and historical alcohol and drug use before death. Deaths by hanging, jumping and self-poisoning were the most common suicide methods. Though deaths by hanging significantly increased over time, deaths by self-poisoning significantly decreased, especially by means of psychotropic medication and opioids. To improve risk management, clinical efforts should focus on identifying and treating people with schizophrenia using specific substances. Nationwide initiatives for improving safety in prescribing could be contributing to reduced risks of suicide via self-poisoning in this group.

Sociodemographic inequalities of suicide: a population-based cohort study of adults in England and Wales 2011-21.

BACKGROUND: The risk of suicide is complex and often a result of multiple interacting factors. Understanding which groups of the population are most at risk of suicide is important to inform the development of targeted public health interventions. METHODS: We used a novel linked dataset that combined the 2011 Census with the population-level mortality data in England and Wales. We fitted generalized linear models with a Poisson link function to estimate the rates of suicide across different sociodemographic groups and to identify which characteristics are independent predictors of suicide. RESULTS: Overall, the highest rates of suicide were among men aged 40-50 years, individuals who reported having a disability or long-term health problem, those who were unemployed long term or never had worked, and those who were single or separated. After adjusting for other characteristics such as employment status, having a disability or long-term health problem, was still found to increase the incidence of suicide relative to those without impairment [incidence rate ratio minimally adjusted (women) = 3.5, 95% confidence interval (CI) = 3.3-3.6; fully adjusted (women) 3.1, 95% CI = 3.0-3.3]. Additionally, while the absolute rate of suicide was lower in women compared with men, the relative risk in people reporting impairments compared with those who do not was higher in women compared with men. CONCLUSIONS: The findings of this work provide novel population-level insights into the risk of suicide by sociodemographic characteristics in England and Wales. Our results highlight several sociodemographic groups who may benefit from more targeted suicide prevention policies and practices.

Psychiatric in-patient care in England: as safe as it can be? An examination of in-patient suicide between 2009 and 2020.

BACKGROUND: Psychiatric in-patients have a greatly elevated risk of suicide. We aimed to examine trends in in-patient suicide rates and determine if characteristics of in-patients who died by suicide have changed over time. METHODS: We identified all in-patients in England who died by suicide between 2009 and 2020 from the National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide rates were calculated using data from Hospital Episodes Statistics. RESULTS: The rate of in-patient suicide per 100 000 bed days fell by 41.9% between 2009-2011 and 2018-2020. However, since 2016 the rate has remained static with no significant fall. Rates fell in men, those aged 30-59, and those with schizophrenia and other delusional disorders or personality disorder. Rates also fell for suicide by hanging (including hanging on the ward) and jumping. No falls were seen in suicide rates among women, younger and older age groups, and those with affective disorder. There was no indication of a transfer of risk to the post-discharge period or to home treatment/crisis care. More in-patients in the latter part of the study were aged under 25, were on authorised leave, and had psychiatric comorbidity. CONCLUSIONS: In-patient suicide has significantly fallen since 2009, suggesting patient safety may have improved. The recent slowdown in the fall in rates, however, highlights that renewed preventative efforts are needed. These should include a greater focus on women, younger and older patients, and those with affective disorder. Careful reviews prior to granting leave are important to ensure a safe transition into the community.

Working conditions, psychological distress and suicidal ideation: cross-sectional survey study of UK junior doctors.

BACKGROUND: Evidence attests a link between junior doctors' working conditions and psychological distress. Despite increasing concerns around suicidality among junior doctors, little is known about its relationship to their working conditions. AIMS: To (a) establish the prevalence of suicidal ideation among junior doctors in the National Health Service; (b) examine the relationships between perceived working conditions and suicidal ideation; and (c) explore whether psychological distress (e.g. symptoms of depression and anxiety) mediates these relationships. METHOD: Junior doctors were recruited between March 2020 and January 2021, for a cross-sectional online survey. We used the Health and Safety Executive's Management Standards Tool; Depression, Anxiety and Stress Scale 21; and Paykel Suicidality Scale to assess working conditions, psychological distress and suicidality, respectively. RESULTS: Of the 424 participants, 50.2% reported suicidal ideation, including 6.1% who had made an attempt on their own life. Participants who identified as LGBTQ+ (odds ratio 2.18, 95% CI 1.15-4.12) or reported depression symptoms (odds ratio 1.10, 95% CI 1.07-1.14) were more likely to report suicidal ideation. No direct relationships were reported between working conditions (i.e. control, support, role clarity, strained relationships, demand and change) and suicidal ideation. However, depression symptoms mediated all six relationships. CONCLUSIONS: This sample of junior doctors reported alarming levels of suicidal ideation. There may be an indirect relationship between working conditions and suicidal ideation via depressive symptoms. Clearer research exploring the experience of suicidality in junior doctors is needed, including those who identify as LGBTQ+. Systematic interventions addressing working environment are needed to support junior doctors' mental health.

Suicide after leaving the UK Armed Forces 1996-2018: A cohort study.

BACKGROUND: There are comparatively few international studies investigating suicide in military veterans and no recent UK-wide studies. This is important because the wider context of being a UK Armed Forces (UKAF) veteran has changed in recent years following a period of intensive operations. We aimed to investigate the rate, timing, and risk factors for suicide in personnel who left the UKAF over a 23-year period. METHODS AND FINDINGS: We carried out a retrospective cohort study of suicide in personnel who left the regular UKAF between 1996 and 2018 linking national databases of discharged personnel and suicide deaths, using survival analysis to examine the risk of suicide in veterans compared to the general population and conditional logistic regression to investigate factors most strongly associated with suicide after discharge. The 458,058 individuals who left the UKAF accumulated over 5,852,100 person years at risk, with a median length of follow-up of 13 years, were mostly male (91%), and had a median age of 26 years at discharge. 1,086 (0.2%) died by suicide. The overall rate of suicide in veterans was slightly lower than the general population (standardised mortality ratio, SMR [95% confidence interval, CI] 94 [88 to 99]). However, suicide risk was 2 to 3 times higher in male and female veterans aged under 25 years than in the same age groups in the general population (age-specific mortality ratios ranging from 160 to 409). Male veterans aged 35 years and older were at reduced risk of suicide (age-specific mortality ratios 47 to 80). Male sex, Army service, discharge between the ages of 16 and 34 years, being untrained on discharge, and length of service under 10 years were associated with higher suicide risk. Factors associated with reduced risk included being married, a higher rank, and deployment on combat operations. The rate of contact with specialist NHS mental health services (273/1,086, 25%) was lowest in the youngest age groups (10% for 16- to 19-year-olds; 23% for 20- to 24-year-olds). Study limitations include the fact that information on veterans was obtained from administrative databases and the role of pre-service vulnerabilities and other factors that may have influenced later suicide risk could not be explored. In addition, information on contact with support services was only available for veterans in contact with specialist NHS mental health services and not for those in contact with other health and social care services. CONCLUSIONS: In this study, we found suicide risk in personnel leaving the UKAF was not high but there are important differences according to age, with higher risk in young men and women. We found a number of factors which elevated the risk of suicide but deployment was associated with lower risk. The focus should be on improving and maintaining access to mental health care and social support for young service leavers, as well as implementing general suicide prevention measures for all veterans regardless of age.

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

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

Self-harm in university students: A comparative analysis of data from the Multicentre Study of Self-harm in England.

BACKGROUND: Increases in poor mental health and suicide have been identified among university students in the UK. However, little is known about self-harm in this group. AIMS: To describe and identify care needs of university aged-students who self-harm via comparisons with an age-equivalent non-student group who self-harm. METHODS: Observational cohort data from The Multicentre Study of Self-harm in England were used to investigate students aged 18 to 24 years who presented to emergency departments for self-harm, 2003 to 2016. Data were collected via clinician reports and medical records from five hospitals in three English regions. Characteristics, rates, repetition, and mortality outcomes were investigated. RESULTS: The student sample included 3491 individuals (983, 28.2 % men; 2507, 71.8 % women; 1 unknown) compared to 7807 (3342, 42.8 % men; 4465, 57.2 % women) non-students. Self-harm increased over time in students (IRR 1.08, 95%CI 1.06-1.10, p < 0.01) but not in non-students (IRR 1.01, 95%CI 1.00-1.02, p = 0.15). There were differences in monthly distribution of self-harm with more presentations by students in October, November, and February. Characteristics were broadly similar, but students reported more problems with studying and mental health. Repetition (HR 0.78, 95%CI 0.71-0.86, p < 0.01) and mortality (HR 0.51, 95%CI 0.33-0.80, p < 0.01) were lower in students than non-students. CONCLUSIONS: Self-harm in students may be directly related the student experience, such as academic pressure, relocation, and the transition to independent living. Wellbeing initiatives targeting these factors, alongside mental health awareness training for academic and non-academic staff may help to support students at risk.

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

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

Risk of suicide after diagnosis of severe physical health conditions: A retrospective cohort study of 47 million people.

Background: The diagnosis of a severe physical health condition can cause psychological distress and lead to severe depression. The association between severe physical health conditions and the risk of suicide, and how the risk of suicide changes in the months following diagnosis, are not clear. Methods: We estimated whether a diagnosis of severe physical health conditions is associated with an increase in the risk of death by suicide using a dataset based on the 2011 Census linked to hospital records and death registration records covering 47,354,696 people alive on 1 January 2017 in England. Patients diagnosed with a low-survival cancer, chronic ischaemic heart disease, chronic obstructive pulmonary disease, or degenerative neurological condition were matched to individuals using socio-demographic characteristics from the Census. Using the Aalen-Johansen estimator, we estimated the cumulative incidence of death by suicide occurring between 1 January 2017 and 31 December 2021 (registered by 31 December 2021) in patients and matched controls, adjusted for other potential confounders using inverse probability weighting. Findings: Diagnosis of severe conditions was associated with an increased risk of dying by suicide. One year after diagnosis, the rate of suicide was 21.6 (95% confidence intervals: 14.9-28.4, number of events (N): 39) per 100,000 low-survival cancer patients compared to 9.5 (5.6-14.6, N:16) per 100,000 matched controls. For COPD patients, the one-year suicide rate was 22.4 (19.4-25.5, N:208) per 100,000 COPD patients (matched controls: 10.6, 8.3-13.0, N:85), for ischaemic heart disease 16.1 (14.1-18.2, N:225) per 100,000 patients (matched controls: 8.8, 7.1-10.4, N:128), for degenerative neurological conditions 114.5 (49.6-194.7, N:11) per 100,000 patients. The increase in risk was more pronounced in the first six months after diagnosis or first treatment. Interpretation: A diagnosis of severe physical illness is associated with higher suicide risk. The interaction of physical and mental illness emphasises the importance of collaborative physical and mental health care in these patients. Funding: The Office for National Statistics. KES is the Laing Galazka chair in palliative care at King's College London, funded by an endowment from Cicely Saunders International and the Kirby Laing Foundation.

Recommendations for improving the working conditions and cultures of distressed junior doctors, based on a qualitative study and stakeholder perspectives.

BACKGROUND: Doctors, including junior doctors, are vulnerable to greater levels of distress and mental health difficulties than the public. This is exacerbated by their working conditions and cultures. While this vulnerability has been known for many years, little action has been taken to protect and support junior doctors working in the NHS. As such, we present a series of recommendations from the perspective of junior doctors and other relevant stakeholders, designed to improve junior doctors' working conditions and, thus, their mental health. METHODS: We interviewed 36 junior doctors, asking them for recommendations for improving their working conditions and culture. Additionally, we held an online stakeholder meeting with a variety of healthcare professionals (including junior doctors), undergraduate medical school leads, postgraduate speciality school leads and NHS policymakers where we asked what could be done to improve junior doctors' working conditions. We combined interview data with notes from the stakeholder discussions to produce this set of recommendations. RESULTS: Junior doctor participants and stakeholders made organisational and interpersonal recommendations. Organisational recommendations include the need for more environmental, staff and educational resources as well as changes to rotas. Interpersonal recommendations include changes to communication and recommendations for better support and teamwork. CONCLUSION: We suggest that NHS policymakers, employers and managers consider and hopefully implement the recommendations set out by the study participants and stakeholders as reported in this paper and that the gold standards of practice which are reported here (such as examples of positive learning environments and supportive supervision) are showcased so that others can learn from them.

Suicide numbers during the first 9-15 months of the COVID-19 pandemic compared with pre-existing trends: An interrupted time series analysis in 33 countries.

Background: Predicted increases in suicide were not generally observed in the early months of the COVID-19 pandemic. However, the picture may be changing and patterns might vary across demographic groups. We aimed to provide a timely, granular picture of the pandemic's impact on suicides globally. Methods: We identified suicide data from official public-sector sources for countries/areas-within-countries, searching websites and academic literature and contacting data custodians and authors as necessary. We sent our first data request on 22nd June 2021 and stopped collecting data on 31st October 2021. We used interrupted time series (ITS) analyses to model the association between the pandemic's emergence and total suicides and suicides by sex-, age- and sex-by-age in each country/area-within-country. We compared the observed and expected numbers of suicides in the pandemic's first nine and first 10-15 months and used meta-regression to explore sources of variation. Findings: We sourced data from 33 countries (24 high-income, six upper-middle-income, three lower-middle-income; 25 with whole-country data, 12 with data for area(s)-within-the-country, four with both). There was no evidence of greater-than-expected numbers of suicides in the majority of countries/areas-within-countries in any analysis; more commonly, there was evidence of lower-than-expected numbers. Certain sex, age and sex-by-age groups stood out as potentially concerning, but these were not consistent across countries/areas-within-countries. In the meta-regression, different patterns were not explained by countries' COVID-19 mortality rate, stringency of public health response, economic support level, or presence of a national suicide prevention strategy. Nor were they explained by countries' income level, although the meta-regression only included data from high-income and upper-middle-income countries, and there were suggestions from the ITS analyses that lower-middle-income countries fared less well. Interpretation: Although there are some countries/areas-within-countries where overall suicide numbers and numbers for certain sex- and age-based groups are greater-than-expected, these countries/areas-within-countries are in the minority. Any upward movement in suicide numbers in any place or group is concerning, and we need to remain alert to and respond to changes as the pandemic and its mental health and economic consequences continue. Funding: None.

Relationship between working conditions and psychological distress experienced by junior doctors in the UK during the COVID-19 pandemic: a cross-sectional survey study.

OBJECTIVES: This paper explored the self-reported prevalence of depression, anxiety and stress among junior doctors during the COVID-19 pandemic. It also reports the association between working conditions and psychological distress experienced by junior doctors. DESIGN: A cross-sectional online survey study was conducted, using the 21-item Depression, Anxiety and Stress Scale and Health and Safety Executive scale to measure psychological well-being and working cultures of junior doctors. SETTING: The National Health Service in the UK. PARTICIPANTS: A sample of 456 UK junior doctors was recruited online during the COVID-19 pandemic from March 2020 to January 2021. RESULTS: Junior doctors reported poor mental health, with over 40% scoring extremely severely depressed (45.2%), anxious (63.2%) and stressed (40.2%). Both gender and ethnicity were found to have a significant influence on levels of anxiety. Hierarchical multiple linear regression analysis outlined the specific working conditions which significantly predicted depression (increased demands (ß=0.101), relationships (ß=0.27), unsupportive manager (ß=-0.111)), anxiety (relationships (ß=0.31), change (ß=0.18), demands (ß=0.179)) and stress (relationships (ß=0.18), demands (ß=0.28), role (ß=0.11)). CONCLUSIONS: The findings illustrate the importance of working conditions for junior doctors' mental health, as they were significant predictors for depression, anxiety and stress. Therefore, if the mental health of junior doctors is to be improved, it is important that changes or interventions specifically target the working environment rather than factors within the individual clinician.

Intimate partner violence, suicidality, and self-harm: a probability sample survey of the general population in England.

BACKGROUND: Intimate partner violence (IPV) is a recognised risk factor for psychiatric disorders. There is little current evidence on IPV and self-harm and suicidality, and we therefore aimed to investigate the associations between experience of lifetime and past-year IPV with suicidal thoughts, suicide attempt, and self-harm in the past year. METHODS: We analysed the 2014 Adult Psychiatric Morbidity Survey, a cross-sectional survey of 7058 adults (aged ≥16 years) in England, which used a multistage random probability sampling design and involved face-to-face interviews. Participants were asked about experience of physical violence and sexual, economic, and emotional abuse from a current or former partner, and about suicidal thoughts, suicide attempts, and self-harm. Other adversities were recorded through an adapted version of the List of Threatening Experiences. Multivariable logistic regression models quantified associations between different indicators of lifetime and past-year IPV, with past-year non-suicidal self-harm, suicidal thoughts, and suicide attempts. All analyses were weighted. FINDINGS: Using weighted percentages, we found that a fifth (21·4%) of 7058 adults reported lifetime experience of IPV, and that 27·2% of women and 15·3% of men had experienced IPV. Among women, 19·6% had ever experienced emotional IPV, 18·7% physical IPV, 8·5% economic IPV, and 3·7% sexual IPV, which was higher than in men (8·6%, 9·3%, 3·6%, and 0·3%, respectively). Findings for ethnicity were unclear. Lifetime prevalence of IPV was higher in those living in rented accommodation or deprived neighbourhoods. Among people who had attempted suicide in the past year, 49·7% had ever experienced IPV and 23·1% had experienced IPV in the past year (including 34·8% of women and 9·4% of men). After adjusting for demographics, socioeconomics, and lifetime experience of adversities, the odds ratio of a past-year suicide attempt were 2·82 (95% CI 1·54-5·17) times higher in those who have ever experienced IPV, compared with those who had not. Fully adjusted odds ratios for past-year self-harm (2·20, 95% CI 1·37-3·53) and suicidal thoughts (1·85, 1·39-2·46) were also raised in those who had ever experienced IPV. INTERPRETATION: IPV is common in England, especially among women, and is strongly associated with self-harm and suicidality. People presenting to services in suicidal distress or after self-harm should be asked about IPV. Interventions designed to reduce the prevalence and duration of IPV might protect and improve the lives of people at risk of self-harm and suicide. FUNDING: UK Prevention Research Partnership.

Self-harm in people experiencing homelessness: investigation of incidence, characteristics and outcomes using data from the Multicentre Study of Self-Harm in England.

BACKGROUND: People who experience homelessness are thought to be at high risk of suicide, but little is known about self-harm in this population. AIMS: To examine characteristics and outcomes in people experiencing homelessness who presented to hospital following self-harm. METHOD: Data were collected via specialist assessments and/or hospital patient records from emergency departments in Manchester, Oxford and Derby, UK. Data were collected from 1 January 2000 to 31 December 2016, with mortality follow-up via data linkage with NHS Digital to 31 December 2019. Trend tests estimated change in self-harm over time; descriptive statistics described characteristics associated with self-harm. Twelve-month repetition and long-term mortality were analysed using Cox proportional hazards models and controlled for age and gender. RESULTS: There were 4841 self-harm presentations by 3270 people identified as homeless during the study period. Presentations increased after 2010 (IRR = 1.09, 95% CI 1.04-1.14, P < 0.001). People who experienced homelessness were more often men, White, aged under 54 years, with a history of previous self-harm and contact with psychiatric services. Risk of repetition was higher than in domiciled people (HR = 2.05, 95% CI 1.94-2.17, P < 0.001), as were all-cause mortality (HR = 1.45, 95% CI 1.32-1.59. P < 0.001) and mortality due to accidental causes (HR = 2.93, 95% CI 2.41-3.57, P < 0.001). CONCLUSIONS: People who self-harm and experience homelessness have more complex needs and worse outcomes than those who are domiciled. Emergency department contact presents an opportunity to engage people experiencing homelessness with mental health, drug and alcohol, medical and housing services, as well as other sources of support.

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

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

What challenges did junior doctors face while working during the COVID-19 pandemic? A qualitative study.

OBJECTIVES: This paper reports findings exploring junior doctors' experiences of working during the COVID-19 pandemic in the UK. DESIGN: Qualitative study using in-depth interviews with 15 junior doctors. Interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.12 to facilitate data management. Data were analysed using reflexive thematic analysis. SETTING: National Health Service (NHS) England. PARTICIPANTS: A purposive sample of 12 female and 3 male junior doctors who indicated severe depression and/or anxiety on the DASS-21 questionnaire or high suicidality on Paykel's measure were recruited. These doctors self-identified as having lived experience of distress due to their working conditions. RESULTS: We report three major themes. First, the challenges of working during the COVID-19 pandemic, which were both personal and organisational. Personal challenges were characterised by helplessness and included the trauma of seeing many patients dying, fears about safety and being powerless to switch off. Work-related challenges revolved around change and uncertainty and included increasing workloads, decreasing staff numbers and negative impacts on relationships with colleagues and patients. The second theme was strategies for coping with the impact of COVID-19 on work, which were also both personal and organisational. Personal coping strategies, which appeared limited in their usefulness, were problem and emotion focused. Several participants appeared to have moved from coping towards learnt helplessness. Some organisations reacted to COVID-19 collaboratively and flexibly. Third, participants reported a positive impact of the COVID-19 pandemic on working practices, which included simplified new ways of working-such as consistent teams and longer rotations-as well as increased camaraderie and support. CONCLUSIONS: The trauma that junior doctors experienced while working during COVID-19 led to powerlessness and a reduction in the benefit of individual coping strategies. This may have resulted in feelings of resignation. We recommend that, postpandemic, junior doctors are assigned to consistent teams and offered ongoing support.

Child suicide rates during the COVID-19 pandemic in England.

BACKGROUND: There is concern about the impact of COVID-19, and the control measures to prevent the spread, on children's mental health. The aim of this work was to identify if there had been a rise of childhood suicide during the COVID pandemic. METHOD: Using data from England's National Child Mortality Database (NCMD) the characteristics and rates of children dying of suicide between April and December 2020 were compared with those in 2019. In a subset (1st January to 17th May 2020) further characteristics and possible contributing factors were obtained. RESULTS: A total of 193 likely childhood deaths by suicide were reported. There was no evidence overall suicide deaths were higher in 2020 than 2019 (RR 1.09 (0.80-1.48), p = 0.584) but weak evidence that the rate in the first lockdown period (April to May 2020) was higher than the corresponding period in 2019 (RR 1.56 (0.86-2.81), p = 0.144). Characteristics of individuals were similar between periods. Social restrictions (e.g. to education), disruption to care and support services, tensions at home and isolation appeared to be contributing factors. LIMITATIONS: As child suicides are fortunately rare, the analysis is based on small numbers of deaths with limited statistical power to detect anything but major increases in incidence. CONCLUSION: We found no consistent evidence that child suicide deaths increased during the COVID-19 pandemic although there was a possibility that they may have increased during the first UK lockdown. A similar peak was not seen during the following months, or the second lockdown.

Suicide rates by ethnic group among patients in contact with mental health services: an observational cohort study in England and Wales.

BACKGROUND: Recent evidence on suicide rates among psychiatric patients from minority ethnic backgrounds is scarce. We aimed to examine suicide rates among minority ethnic psychiatric patients and describe their social and clinical characteristics. METHODS: We did a retrospective observational cohort study on a national case-series of patients in England and Wales who died by suicide within 12 months of contact with mental health services between 2007 and 2018. Data were collected as part of the National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide rates and standardised mortality ratios (SMRs) were estimated for South Asian (Indian, Pakistani, and Bangladeshi), Black African, Black Caribbean, Chinese, and White patients. FINDINGS: A total of 698 patients in the four minority ethnic groups of South Asian, Black Caribbean, Black African, and Chinese were included (482 [69%] men; 216 [31%] women; mean age 41 years [SD 14·9, range 12-91] and compared with 13 567 White patients (9030 [66·6%] men; 4537 [33·4%] women; mean age 48 years [SD 15·8, range 10-100]). Rates and SMRs for suicide among minority ethnic patients were lower than for White patients (2·73 deaths, 95% CI 2·68-2·78) per 100 000 population. Differences were found between ethnic groups with higher suicide rates in Black Caribbean patients (1·89 deaths [95% CI 1·55-2·23] per 100 000 population) and lower rates in South Asian patients (1·49 deaths [1·33-1·64] per 100 000 population). There was an increase in rates among White patients in 2007-12 followed by a fall but no change among other ethnic groups. Schizophrenia was more common among Black African patients (54%) and Black Caribbean patients (44%), while affective disorder was more common among South Asian patients (41%). Minority ethnic patients overall showed markers of social adversity and received higher intensity care yet were viewed by clinicians as at lower risk than White patients. INTERPRETATION: Effective approaches to prevention might differ between minority ethnic groups. Clinicians and the services in which they work should be aware of the common and distinct social and clinical needs of minority ethnic patients with mental illness. FUNDING: The Healthcare Quality Improvement Partnership.