Time trends in coroners' use of different verdicts for possible suicides and their impact on officially reported incidence of suicide in England: 1990-2005.

BACKGROUND: Official suicide statistics for England are based on deaths given suicide verdicts and most cases given an open verdict following a coroner's inquest. Previous research indicates that some deaths given accidental verdicts are considered to be suicides by clinicians. Changes in coroners' use of different verdicts may bias suicide trend estimates. We investigated whether suicide trends may be over- or underestimated when they are based on deaths given suicide and open verdicts. Method Possible suicides assessed by 12 English coroners in 1990/91, 1998 and 2005 and assigned open, accident/misadventure or narrative verdicts were rated by three experienced suicide researchers according to the likelihood that they were suicides. Details of all suicide verdicts given by these coroners were also recorded. RESULTS: In 1990/91, 72.0% of researcher-defined suicides received a suicide verdict from the coroner, this decreased to 65.4% in 2005 (p trend < 0.01); equivalent figures for combined suicide and open verdicts were 95.4% (1990/91) and 86.7% (2005). Researcher-defined suicides with a verdict of accident/misadventure doubled over that period, from 4.6% to 9.1% (p < 0.01). Narrative verdict cases rose from zero in 1990/91 to 25 in 2005 (4.2% of researcher-defined suicides that year). In 1998 and 2005, 50.0% of the medicine poisoning deaths given accidental/misadventure verdicts were rated as suicide by the researchers. CONCLUSIONS: Between 1990/91 and 2005, the proportion of researcher-defined suicides given a suicide verdict by coroners decreased, largely due to an increased use of accident/misadventure verdicts, particularly for deaths involving poisoning. Consideration should be given to the inclusion of 'accidental' deaths by poisoning with medicines in the statistics available for monitoring suicides rates.

What can be done to reduce mortality from paracetamol overdoses? A patient interview study.

BACKGROUND: Paracetamol (acetaminophen) is the most common self-poisoning agent in the UK and a leading cause of fatal hepatotoxicity. Following legislation in 1998 to limit pack sizes, beneficial effects on paracetamol-related mortality and morbidity were reported in England. However, there are still over 100 deaths a year and evidence of breaches of sales guidelines. AIM: To investigate characteristics of people taking larger paracetamol overdoses and compliance with sales guidelines, to inform possible further initiatives to reduce paracetamol fatalities. DESIGN AND METHODS: Interview study of 60 general hospital patients who took overdoses of over 16 paracetamol tablets (8 g). RESULTS: Half of all paracetamol overdoses involved over 16 tablets. Patients were predominantly young (three-quarters aged 16-40 years) and female (58.3%); over half (53.3%) had taken a previous paracetamol overdose. Three-quarters said they wanted to die. Half took the overdose within an hour of first thinking of it, half (53.3%) took tablets already in the home and 58.3% bought tablets specifically for the overdose. Ten people tried to buy more than 32 tablets in one transaction; four succeeded. Most knew that a paracetamol overdose could cause death or permanent damage (88.3%) and harm the liver (80.0%) but 70.0% thought they would lose consciousness. Warnings on packs had little deterrent effect. Media and internet influences were identified. Patients chose paracetamol because it was cheap and easily available. CONCLUSIONS: Further measures to reduce breaches of sales guidelines and the dangers of paracetamol overdose are required. Media and internet site producers should follow guidelines on reporting suicide.

[Surgical prophylactics of bronchopleural fistulas after pneumonectomy].

The authors made an analysis of the results of treatment of 924 patients with non-small cell lung cancer, operated in the volume of pneumonectomy during 1990-2007 years and developed a method of complete suturing the mediastinum wound in order to isolate the bronchus stump from the free pleural cavity and prevention of the development of a bronchopleural fistula.

Systematic review of the prevalence of suicide in veterinary surgeons.

BACKGROUND: An accumulating body of research demonstrates that risk of suicide varies between occupational groups. Identification of the occupations at risk, and the factors that contribute to the increased risk of suicide in these groups is essential for the development of effective suicide prevention strategies. There is preliminary evidence to suggest that veterinary surgeons are a group at risk. AIMS: To conduct a systematic review of studies of rates and methods of suicide in the veterinary profession. METHODS: A systematic search of the international research literature was performed in May 2008. The data from the 19 studies of the prevalence of suicide in the veterinary profession were extracted by two independent reviewers and analysed. RESULTS: Between 0 and 43% of veterinary surgeon deaths were due to suicide. In all but one of the 15 studies presenting risk of suicide in veterinary surgeons with a comparison population, an elevated risk was found. The better quality studies with the lowest risk of bias indicated that in the UK, the rate of suicide in the veterinary profession was at least three times the general population rate. Studies of the methods of suicide veterinary surgeons use suggest that self-poisoning and firearms are particularly common. CONCLUSIONS: There appears to be an elevated risk of suicide for veterinary surgeons in several countries. Access to means of suicide influences the methods used and may contribute to increased risk.

Incidence of alcohol-related deaths in the veterinary profession in England and Wales, 1993-2005.

It has recently been shown that the proportional mortality ratio for suicide by veterinarians is one of the highest of all occupational groups. The reasons for this alarming statistic are unclear although it has been postulated that alcohol or drug misuse may be significant risk factors which contribute towards the high incidence of suicide within the profession. However, there have been few studies on alcohol misuse by veterinarians and so the aim of this study was to investigate the incidence of alcohol-related deaths in the veterinary profession in England and Wales between 1993 and 2005. The proportional mortality ratio for alcohol-related deaths for veterinarians was not significantly higher than the general population during this time period. Future studies should focus on establishing the incidence of sub-lethal alcohol misuse within the veterinary profession.

Self-poisoning suicides in England: a multicentre study.

BACKGROUND: Suicide by self-poisoning is an important cause of death worldwide. A substantial proportion of those with a fatal outcome may come into contact with medical services before they die. AIM: To estimate the proportion of self-poisoning suicides who reached hospital alive; to compare those who reached hospital alive with those who did not; to describe in detail the clinical characteristics and medical management of those dying in hospital. DESIGN: Retrospective audit. METHODS: We studied 24 coroners' jurisdictions across England, reviewing coroners' files and identifying all suicides by self-poisoning (drugs and other ingestible poisons) from 1 January 2001 to 31 December 2001. RESULTS: Of the 214 individuals who completed suicide by self-poisoning during the study period, 49 (23%) reached hospital alive. Those reaching hospital were more likely to be female, more likely to have ingested paracetamol and less likely to have ingested co-proxamol. In the hospital sample, the commonest causes of death were respiratory (n = 10), hepatic or hepatorenal (n = 8), cardiac (n = 5), or a result of hypoxic brain injury (n = 5). Only 18% of in-hospital deaths occurred within 24 h of the overdose. DISCUSSION: Extrapolating to England as a whole, we might expect 300 self-poisoning suicides per year to reach hospital alive (6% of all suicides). Improved medical management might produce a small but significant reduction in the rate of suicide. Such interventions should not be restricted to the emergency care domain. Further research will help to clarify the likely contribution of improved medical management to suicide prevention.

Co-proxamol and suicide: preventing the continuing toll of overdose deaths.

Restricting means for suicide is a key element in suicide prevention strategies of all countries where these have been introduced. Preventing deaths from analgesic overdoses is highlighted in the National Suicide Prevention Strategy for England. The problem of self-poisoning with the prescription-only drug co-proxamol (dextropropoxyphene plus paracetamol) has received attention in several countries. We have conducted a review of the international literature related to possible strategies to tackle this problem. In England and Wales in 1997-1999, 18% of drug-related suicides involved co-proxamol; these constituted 5% of all suicides. Death usually results from the toxic effects of dextropropoxyphene on respiration or cardiac function. Death from co-proxamol overdose may occur rapidly, the lethal dose can be relatively low, and the effects are potentiated by alcohol and other CNS depressants. The majority of co-proxamol overdose deaths occur before hospital treatment can be received. The risk can extend to others in the household of the person for whom the drug is prescribed. While there is limited evidence that educational strategies have been effective in reducing deaths from co-proxamol poisoning, initiatives in Scandinavia, Australia and the UK to restrict availability of co-proxamol have produced promising results. Given the paucity of evidence for superior therapeutic efficacy of co-proxamol over other less toxic analgesics, there are good reasons to question whether it should continue to be prescribed.

A multicentre study of coproxamol poisoning suicides based on coroners' records in England.

AIMS: To examine in detail a series of coproxamol overdose deaths in order to provide information that will assist in the development of strategies to prevent such fatalities. METHOD: Inquest records in 24 coroners' jurisdictions in England on deaths between January 2000 and December 2001 which received a verdict of either suicide or undetermined cause (with a high or moderate probability of suicide) were examined. RESULTS: One hundred and twenty-three coproxamol poisoning suicides were identified. Alcohol was involved in 58.5% of the overdoses and these individuals generally had lower blood drug levels and consumed fewer tablets. Younger people were more likely to have consumed alcohol and to have lower levels of suicide intent. Nearly half the individuals had a history of self harm, and a third were under psychiatric care. The coproxamol had been prescribed for the individual in 81.5% of cases, although only in 55.0% of those aged 10-34 years. In other cases the source of the coproxamol was nearly always a family member or partner. Some deaths resulted from relatively small overdoses. CONCLUSIONS: Strategies to reduce self poisoning deaths due to coproxamol should take account of the high toxicity of coproxamol in overdose, especially when combined with alcohol, and the fact that risk of death extends beyond the person for whom the drug is prescribed.

Deliberate self-harm in Oxford, 1990-2000: a time of change in patient characteristics.

BACKGROUND: Trends in deliberate self-harm (DSH) are important because they have implications for hospital services, may indicate levels of psychopathology in the community and future trends in suicide, and can assist in identification of means of suicide prevention. METHOD: We have investigated trends in DSH and characteristics of DSH patients between 1990 and 2000 based on data collected through the Oxford Monitoring System for Attempted Suicide. RESULTS: During the 11-year study period 8590 individuals presented following 13858 DSH episodes. The annual numbers of persons and episodes increased overall by 36.3% and 63.1% respectively. Rates (Oxford City) declined, however, in the final 3 years. There were gender- and age-specific changes, with a rise in DSH rates in males aged > or = 55 years and in females overall and those aged 15-24 years and 35-54 years. Repetition of DSH increased markedly during the study period. Antidepressant overdoses, especially of SSRIs, increased substantially. Paracetamol overdoses declined towards the end of the study period. Alcohol abuse, use of alcohol in association with DSH, and violence increased, especially in females, and the proportion of patients in current psychiatric care and misusing drugs also rose. CONCLUSIONS: While overall rates of DSH did not increase markedly between 1990 and 2000, substantial changes in the characteristics of the DSH population and a rise in repetition suggest that the challenges facing clinical services in the management of DSH patients have grown.

Suicide in female nurses in England and Wales.

BACKGROUND: Female nurses appear to have an increased risk of suicide but the reasons are unknown. METHOD: We have concluded a study of nurse suicides (N = 106) in England and Wales, including a psychological autopsy study (N = 42) and case-control comparison with living nurses (N = 84). RESULTS: Nearly three-quarters of the nurse suicides had previous contact with psychiatric services and almost half had been psychiatric in-patients in the past. There were particularly marked differences between the cases and controls for current psychiatric disorder (90.5% v. 7.1%, OR = 68.5), personality disorder (38.1% v. 12%, OR = 32), and history of deliberate self-harm (71.4% v. 2.4%, OR = 58.5). Family background and social factors (especially concerning interpersonal relationships) also distinguished the two groups. Smoking and serious alcohol abuse were much more frequent in the suicides. There was some indication that while many of the suicides were in contact with psychiatric services, care may not have been optimal in some cases. CONCLUSIONS: The most important strategies for suicide prevention in nurses are in prevention, detection and management of psychiatric disorders. In assessing suicide risk a history of DSH and the presence of comorbid psychiatric and personality disorders are particularly important.

The influence of the economic and social environment on deliberate self-harm and suicide: an ecological and person-based study.

BACKGROUND: Geographic variations in the incidence of deliberate self-harm (DSH) and suicide have been shown to be associated with area-based measures of socio-economic deprivation and social fragmentation. Previous studies have been subject to methodological limitations. None has investigated whether ecological associations are reflected in characteristics of individuals involved in suicidal behaviour. METHODS: DSH patients presenting to a general hospital between 1985 and 1995 and suicides (including open verdicts) from the same catchment area were studied. Mean annual rates of DSH and suicide by gender were calculated for electoral wards. The wards were amalgamated into 20 groups according to their ranking for socio-economic deprivation (Townsend) and social fragmentation scores. Associations of these variables with DSH and suicide rates were investigated. Characteristics of DSH patients living in ward groups with the highest and lowest socio-economic deprivation and social fragmentation scores were compared. RESULTS: Socio-economic deprivation was associated with DSH rates among males (r = 0.89) and females (r = 0.87). After controlling for social fragmentation the associations remained relatively strong, particularly in young males. Associations with social fragmentation in both genders (males, r = 0.83; females, r = 0.86) were attenuated after controlling for socio-economic deprivation. For suicide, the only significant association was with socio-economic deprivation in males (r = 0.79), but this was attenuated after controlling for social fragmentation. The characteristics of individual DSH patients reflected those of the areas where they lived. CONCLUSIONS: Reducing socio-economic deprivation and its associated problems may be an important strategy in the prevention of suicidal behaviour, especially in young men.

Suicide in doctors: a study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995.

STUDY OBJECTIVE: To investigate the suicide risk of doctors in England and Wales, according to gender, seniority and specialty. DESIGN: Retrospective cohort study. Suicide rates calculated by gender, age, specialty, seniority and time period. Standardised mortality ratios calculated for suicide (1991-1995), adjusted for age and sex. SETTING: England and Wales. SUBJECTS: Doctors in the National Health Service who died by suicide between 1979 and 1995, identified by death certificates. Population at risk based on Department of Health manpower data. MAIN RESULTS: Two hundred and twenty three medical practitioners in the National Health Service who died by suicide or undetermined cause were identified. The annual suicide rates in male and female doctors were 19.2 and 18.8 per 100 000 respectively. The suicide rate in female doctors was higher than in the general population (SMR 201.8; 95% CI 99.7, 303.9), whereas the rate in male doctors was less than that of the general population (SMR 66.8; 95% CI 46.6, 87.0). The difference between the mortality ratios of the female and male doctors was statistically significant (p=0.01), although the absolute suicide risk was similar in the two genders. There were significant differences between specialties (p=0.0001), with anaesthetists, community health doctors, general practitioners and psychiatrists having significantly increased rates compared with doctors in general hospital medicine. There were no differences with regard to seniority and time period. CONCLUSIONS: There is an increased risk of suicide in female doctors, but male doctors seem to be at less risk than men in the general population. The excess risk of suicide in female doctors highlights the need to tackle stress and mental health problems in doctors more effectively. The risk requires particular monitoring in the light of the very large increase in the numbers of women entering medicine.

Social class and suicidal behaviour: the associations between social class and the characteristics of deliberate self-harm patients and the treatment they are offered.

BACKGROUND: Rates of deliberate self-harm (DSH) in the United Kingdom are much higher in lower than upper social class groups. Previous investigations have shown differences in socio-demographic and clinical characteristics of male patients according to social class. In two studies of DSH patients in Edinburgh the extent of provision of psychiatric aftercare was inversely related to social class. These findings have not been investigated in other areas. METHOD: Data collected through the Oxford Monitoring System for Attempted Suicide were used to examine the association between social class and socio-demographic and clinical characteristics in male and female DSH patients who presented to the general hospital in Oxford between mid-1988 and 1996 and to determine whether the previously reported social class differences in provision of psychiatric aftercare were replicated. RESULTS: Data on social class were available for 2,828 DSH patients (1,290 males, 1,538 females). In both genders, lower social class group tended to be associated with younger age. In males, the main social class differences were found in under-35-year-olds, in whom lower social class was related to criminal record, violence to others and drug misuse. In females, psychiatric disorders were diagnosed more frequently in the higher social class groups, but only in the under-35 age group. In neither gender was there a significant association between social class and the frequency of offer of psychiatric aftercare following DSH. CONCLUSIONS: There are considerable variations in socio-demographic and clinical characteristics of both male and female DSH patients in different social classes, especially in younger patients. The reason for the absence of a marked social class gradient in psychiatric aftercare found in this study in contrast to the results from previous investigations may be related to differences in styles of service.

Effect of death of Diana, princess of Wales on suicide and deliberate self-harm.

BACKGROUND: The death of the Princess of Wales in 1997 was followed by widespread public mourning. Such major events may influence suicidal behaviour. AIMS: To assess the impact of the Princess's death on suicide and deliberate self-harm (DSH). METHOD: Analysis, using Poisson regression, of the number of suicides and open verdicts ('suicides') in England and Wales following the Princess's death compared to the 3 months beforehand, and the equivalent periods in 1992-1996. Similar analysis on DSH presentations to a general hospital. RESULTS: Suicides increased during the month following the Princess's funeral (+17.4%). This was particularly marked in females (+33.7%), especially those aged 25-44 years (+45.1%). Suicides did not fall in the week between the death and the funeral. Presentations for DSH increased significantly during the week following the death (+44.3%), especially in females (+65.1%). Examination of case notes suggested that the influence of the death was largely through amplification of personal losses or exacerbation of existing distress. CONCLUSIONS: The death of a major public figure can influence rates of suicidal behaviour. For DSH, the impact may be immediate, but for suicide it may be delayed.

Doctors who kill themselves: a study of the methods used for suicide.

Medical practitioners have a relatively high rate of suicide. Death entry data for doctors who died by suicide or undetermined cause between 1979 and 1995 in England and Wales were used to compare methods used for suicide by doctors with those used by the general population. Methods used were analysed according to gender, occupational status and speciality, to assess the extent to which access to dangerous means influences the pattern of suicide. Self-poisoning with drugs was more common in the doctors than in general population suicides (57% vs. 26.6%; OR=3.65, 95% CI 2.85-4. 68), including in retired doctors. Barbiturates were the most frequent drugs used. Half of the anaesthetists who died used anaesthetic agents. Self-cutting was also more frequently used as a method of suicide. The finding that the greater proportion of suicide deaths in doctors were by self-poisoning may reflect the fact that doctors have ready access to drugs, and have knowledge of which drugs and doses are likely to cause death. The specific finding that a large proportion of suicides in anaesthetists involved anaesthetic agents supports this explanation. Availability of method may be a factor contributing to the relatively high suicide rate of doctors. This fact might influence clinical management of doctors who are known to be depressed or suicidal.

Deliberate self-harm in adolescents in Oxford, 1985-1995.

Deliberate self-harm (DSH) has been one of the major health problems of adolescents in the U.K. for many years. Any changes in rates of DSH or the demographic characteristics of the patient population are likely to have important implications for clinical services and for future suicidal behaviour. Following a decline in rates in the late 1970s and mid 1980s, there were signs in the late 1980s that rates were beginning to increase again. We have used data collected by the Oxford Monitoring System for Attempted Suicide on the basis of patients presenting to the general hospital in Oxford to review trends in DSH in under 20-year-olds between 1985 and 1995. There was a substantial increase in the numbers of teenage DSH patients during the 11-year study period, with an increase between 1985-1986 and 1994-1995 of 27.7% in males, 28.3% in females, and 28.1% overall. There were no demographic changes within the catchment area to explain a change of this size. As rates of repetition of DSH also increased in both sexes during the study period the overall number of episodes of DSH rose even more between 1985-1986 and 1994-1995 (+56.9% in males, +46.3% in females, and +49.4% overall). As in previous studies the majority of adolescents had interpersonal problems and/or difficulties with studying or employment. Self-poisoning with paracetamol and paracetamol compounds became increasingly common such that by 1995 these were used in almost two-thirds of overdoses. The recent increase in DSH in adolescents has important implications for general hospital and adolescent psychiatric services. The greater frequency of repetition of DSH may herald increased future suicide rates. The case for restricting the amount of paracetamol available is overwhelming. Evaluative trials of specific interventions following adolescent DSH are urgently required.

The geographical distribution of suicides in farmers in England and Wales.

Farmers in England and Wales have an elevated risk of suicide. The aim of this study was to investigate the geographical distribution of suicides in farmers. Rates of suicide (including suicide and open verdicts) of farmers in England and Wales between 1981 and 1993 were calculated on a county basis. Trends in rates and differences in rates between counties, regions and England and Wales were then analysed. There were 719 suicides (634 suicide verdicts and 85 open verdicts). There was evidence of a decline in annual rates of suicide in farmers during the study period in England but not Wales. There was no evidence of geographical heterogeneity of farming suicides according to counties, but a relatively high rate for Devon (N = 62 suicides). County farming suicide rates did not appear to be related to local general population suicide rates, density of farmers or type of farm holding. While identification of counties with relatively large numbers of farming suicides should assist targeting of local preventive programmes, it is clear that any significant prevention strategies should be implemented on a national basis.

Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study.

OBJECTIVES: To determine whether a serious paracetamol overdose in the medical television drama Casualty altered the incidence and nature of general hospital presentations for deliberate self poisoning. DESIGN: Interrupted time series analysis of presentations for self poisoning at accident and emergency departments during three week periods before and after the broadcast. Questionnaire responses collected from self poisoning patients during the same periods. SETTING: 49 accident and emergency departments and psychiatric services in United Kingdom collected incidence data; 25 services collected questionnaire data. SUBJECTS: 4403 self poisoning patients; questionnaires completed for 1047. MAIN OUTCOME MEASURES: Change in presentation rates for self poisoning in the three weeks after the broadcast compared with the three weeks before, use of paracetamol and other drugs for self poisoning, and the nature of overdoses in viewers of the broadcast compared with non-viewers. RESULTS: Presentations for self poisoning increased by 17% (95% confidence interval 7% to 28%) in the week after the broadcast and by 9% (0 to 19%) in the second week. Increases in paracetamol overdoses were more marked than increases in non-paracetamol overdoses. Thirty two patients who presented in the week after the broadcast and were interviewed had seen the episode-20% said that it had influenced their decision to take an overdose, and 17% said it had influenced their choice of drug. The use of paracetamol for overdose doubled among viewers of Casualty after the episode (rise of 106%; 28% to 232%). CONCLUSIONS: Broadcast of popular television dramas depicting self poisoning may have a short term influence in terms of increases in hospital presentation for overdose and changes in the choice of drug taken. This raises serious questions about the advisability of the media portraying suicidal behaviour.