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.

Recession, recovery and suicide in mental health patients in England: time trend analysis.

BACKGROUND: The 2008 economic recession was associated with an increase in suicide internationally. Studies have focused on the impact in the general population with little consideration of the effect on people with a mental illness.AimsTo investigate suicide trends related to the recession in mental health patients in England. METHOD: Using regression models, we studied suicide trends in mental health patients in England before, during and after the recession and examined the demographic and clinical characteristics of the patients. We used data from the National Confidential Inquiry into Suicide and Safety in Mental Health, a national data-set of all suicide deaths in the UK that includes detailed clinical information on those seen by services in the last 12 months before death. RESULTS: Between 2000 and 2016, there were 21 224 suicide deaths by patients aged 16 or over. For male patients, following a steady fall of 0.5% per quarter before the recession (quarterly percent change (QPC) 2000-2009 -0.46%, 95% CI -0.66 to -0.27), suicide rates showed an upward trend during the recession (QPC 2009-2011 2.37%, 95% CI -0.22 to 5.04). Recession-related rises in suicide were found in men aged 45-54 years, those who were unemployed or had a diagnosis of substance dependence/misuse. Between 2012 and 2016 there was a decrease in suicide in male patients despite an increasing number of patients treated. No significant recession-related trends were found in women. CONCLUSIONS: Recession-associated increases in suicide were seen in male mental health patients as well as the male general population, with those in mid-life at particular risk. Support and targeted interventions for patients with financial difficulties may help reduce the risk at times of economic hardship. Factors such as drug and alcohol misuse also need to be considered. Recent decreases in suicide may be related to an improved economic context or better mental healthcare.Declaration of interestN.K. is supported by Greater Manchester Mental Health NHS Foundation Trust. L.A. chairs the National Suicide Prevention Strategy Advisory Group at the Department of Health (of which N.K. is also a member) and is a non-executive Director for the Care Quality Commission. N.K. chairs the National Institute for Health and Care Excellence (NICE) depression in adults guideline and was a topic expert member for the NICE suicide prevention guideline.

Mental health services, suicide and 7-day working.

BACKGROUND: Patients admitted to hospital at the weekend appear to be at increased risk of death compared with those admitted at other times. However, a 'weekend effect' has rarely been explored in mental health and there may also be other times of year when patients are vulnerable. AIMS: To investigate the timing of suicide in high-risk mental health patients. METHOD: We compared the incidence of suicide at the weekend v. during the week, and also in August (the month of junior doctor changeover) v. other months in in-patients, patients within 3 months of discharge and patients under the care of crisis resolution home treatment (CRHT) teams (2001-2013). RESULTS: The incidence of suicide was lower at the weekends for each group (incidence rate ratio (IRR) = 0.88 (95% CI 0.79-0.99) for in-patients, IRR = 0.85 (95% CI 0.78-0.92) for post-discharge patients, IRR = 0.87 (95% CI 0.78-0.97) for CRHT patients). Patients who died by suicide were also less likely to have been admitted at weekends than during the week (IRR = 0.52 (95% CI 0.45-0.60)). The incidence of suicide in August was not significantly different from other months. CONCLUSIONS: We found evidence of a weekend effect for suicide risk among high-risk mental health patients, but with a 12-15% lower incidence at weekends. Our study does not support the claim that safety is compromised at weekends, at least in mental health services.

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-related internet use among mental health patients who died by suicide in the UK: a national clinical survey with case-control analysis.

Background: Suicide-related internet use (SRIU) has been shown to be linked to suicide. However, there is limited research on SRIU among mental health patients, who are at 4 to 7 times increased risk of suicide compared to the general population. This study aims to address this gap by exploring the prevalence of SRIU among mental health patients who died by suicide in the UK and describing their characteristics. Methods: The study was carried out as part of the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH). Data were collected on sociodemographic, clinical, suicide characteristics and engagement in SRIU of patients who died by suicide between 2011 and 2021. The study utilised a case-control design to compare patients who engaged in suicide-related internet use with those who did not. Findings: The presence or absence of SRIU was known for 9875/17,347 (57%) patients; SRIU was known to be present in 759/9875 (8%) patients. The internet was most often used to obtain information on suicide methods (n = 523/759, 69%) and to visit pro-suicide websites (n = 250/759, 33%) with a significant overlap between the two (n = 152/759, 20%). Engaging in SRIU was present across all age groups. The case-control element of the study showed patients who were known to have engaged in SRIU were more likely to have been diagnosed with autism spectrum disorder (OR = 2.13, 95% CI: 1.43-3.18), have a history of childhood abuse (OR = 1.70, 95% CI: 1.36-2.13) and to have received psychological treatment (OR = 1.43, 95% CI: 1.18-1.74) than controls. Additionally, these patients were more likely to have died on or near a salient date (OR = 2.11, 95% CI: 1.61-2.76), such as a birthday or anniversary. Interpretation: The findings affirm SRIU as a feature of suicide among patients of all ages and highlight that clinicians should inquire about SRIU during assessments. Importantly, as the most common type of SRIU can expand knowledge on suicide means, clinicians need to be aware of the association between SRIU and choice of methods. This may be particularly relevant for patients approaching a significant calendar event. Funding: The Healthcare Quality Improvement Partnership.

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

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 the UK 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.

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.

Homicide perpetrated by older people.

OBJECTIVE: This study aims to describe the circumstances in which older people commit homicide, the form of assessment they undergo and to examine the proportion of those who suffer from mental illness. METHODS: The study was carried out as part of the England and Wales National Confidential Inquiry into Suicide and Homicide by People with Mental Illness based on a five-year sample. The Inquiry was notified of the names of those over the age of 60 years convicted of homicide and also the details of the offence, sentencing and outcome in court by the Home Office. The Inquiry collected clinical data of those known to have had contact with mental health services from the responsible service and also retrieved psychiatric reports of those convicted. RESULTS: Homicide incidents perpetrated by older people typically involve a man killing his partner in an impulsive manner. The most common method was by using a sharp instrument (34%), followed by the use of a blunt instrument (26%). The use of firearms was rare (11%). Perpetrators aged 65 years and older were significantly more likely to kill a current or former spouse/partner and less likely to kill an acquaintance. Forty-four per cent of perpetrators over 65 years old suffered from depression at the time of the offence, whereas rates of schizophrenia and alcohol dependence were low. CONCLUSIONS: The information used in the study was extracted from a unique national database of homicide perpetrators. The characteristics and the circumstances of homicides perpetrated by older people are different to other age groups. An older-people homicide may be preventable if depression is identified early in older people.

Suicide bereavement in the UK: Descriptive findings from a national survey.

BACKGROUND: Those bereaved by suicide are a high-risk group of adverse health outcomes and suicidal behavior, yet little is known about the experiences and support needs of these individuals in the UK. METHODS: We conducted a national cross-sectional study using an online survey and analyzed the experiences of 7158 participants who had been bereaved or affected by suicide. RESULTS: Suicide had a major impact on 77% of participants, including those who had lost a friend and those exposed to suicide at a professional level. Mental and physical health problems linked to the suicide were reported in half. Adverse social outcomes and engaging in high-risk behaviors following the suicide were common. Over a third reported suicidal ideation and 8% had attempted suicide as a direct result of the suicide loss. Most had not accessed support services, with the majority viewing provision of local suicide bereavement support as inadequate. CONCLUSIONS: Our results highlight the need for a multi-disciplinary approach in postvention and the provision of proactive outreach to support those bereaved by suicide. Postvention efforts need to acknowledge the death of a friend by suicide as a significant loss.

Electroconvulsive therapy and suicide among the mentally ill in England: a national clinical survey.

We aimed to determine the number and characteristics of psychiatric patients receiving electroconvulsive therapy (ECT) who had subsequently died by suicide. Data were collected on an 8-year (1999-2006) sample of suicide cases in England who had been in recent contact with mental health services. Of 9752 suicides, 71 (1%) were being treated with ECT at the time of death. Although the number of patients who received ECT had fallen substantially over time, the rate of suicide in these individuals showed no clear decrease and averaged 9 deaths per year, or a rate of 10.8 per 10,000 patients treated. These suicide cases were typically older, with high rates of affective disorder and previous self-harm. They were more likely to be an in-patient at the time of death than other suicide cases. Nearly half of the community cases who had received ECT had died within 3 months of discharge. Our results demonstrated that the fall in the use of ECT has not affected suicide rates in patients receiving this treatment. Services appear to acknowledge the high risk of suicide in those receiving ECT. Improvements in care of these severely ill patients may include careful discharge planning and improved observation of in-patients in receipt of ECT.

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

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

Ethnic Minority Groups' Experiences of Suicide Bereavement: A Qualitative Exploratory Study.

It is estimated that between 36,000 and 360,000 people are affected by suicide every year in the UK, and a proportion may develop depression and post-traumatic stress disorder, or engage in high-risk behaviours. Recent systematic analyses have revealed a clear gap in research on suicide bereavement in minority ethnic groups. This study aimed to understand the experiences and support needs of individuals from ethnic minority backgrounds bereaved by suicide and was the first in the UK to investigate this matter. The study was a secondary analysis of data. Participants were 7158 people residing in the UK who completed an online survey about their experiences of suicide. Free-text qualitative responses of 227 participants who did not identify as White British were analysed using thematic analysis. Four themes were identified: maladaptive coping strategies, emotional processes following suicide, lack of support from agencies, and the importance of mental health awareness. Ethnic minority groups reported a lack of support despite attempts to engage with services, noted the prevalence of stigma within ethnic minority groups, and expressed a need to tackle this. These preliminary results suggest that ethnic minority individuals require visible and accessible services that can successfully engage with and support them.

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.

Suicide amongst psychiatric in-patients who abscond from the ward: a national clinical survey.

BACKGROUND: Suicide prevention by mental health services requires an awareness of the antecedents of suicide amongst high risk groups such as psychiatric in-patients. The goal of this study was to describe the social and clinical characteristics of people who had absconded from an in-patient psychiatric ward prior to suicide, including aspects of the clinical care they received. METHODS: We carried out a national clinical survey based on a 10-year (1997-2006) sample of people in England and Wales who had died by suicide. Detailed data were collected on those who had been in contact with mental health services in the year before death. RESULTS: There were 1,851 cases of suicide by current psychiatric in-patients, 14% of all patient suicides. 1,292 (70%) occurred off the ward. Four hundred and sixty-nine of these patients died after absconding from the ward, representing 25% of all in-patient suicides and 38% of those that occurred off the ward. Absconding suicides were characterised by being young, unemployed and homeless compared to those who were off the ward with staff agreement. Schizophrenia was the most common diagnosis, and rates of previous violence and substance misuse were high. Absconders were proportionally more likely than in-patients on agreed leave to have been legally detained for treatment, non-compliant with medication, and to have died in the first week of admission. Whilst absconding patients were significantly more likely to have been under a high level of observation, clinicians reported more problems in observation due to either the ward design or other patients on the ward. CONCLUSION: Measures that may prevent absconding and subsequent suicide amongst in-patients might include tighter control of ward exits, and more intensive observation of patients, particularly in the early days of admission. Improving the ward environment to provide a supportive and less intimidating experience may contribute to reduced risk.

Homicide by men diagnosed with schizophrenia: national case-control study.

BACKGROUND: Some people diagnosed with schizophrenia are more prone to committing acts of serious violence, especially in the presence of drug or alcohol misuse. The rarity of homicide has meant that no large controlled study has previously examined clinical risk factors. AIMS: To determine the risk factors for homicide by males diagnosed with schizophrenia. METHOD: A national nested case-control study of all previously admitted males diagnosed with schizophrenia, convicted of homicide between 1 January 1997 and 31 December 2012. Univariate and multivariable conditional logistic regression models were fitted to identify predictors of homicide in this population. RESULTS: During the observation period 160 male patients with schizophrenia and a history of psychiatric admission were convicted of homicide, and they were matched with 542 male control patients who had not been convicted of homicide. Patients who committed homicide were more likely to have a history of violence and comorbid personality disorder or drug misuse. They were more likely to have missed their last contact with services prior to the offence and to have been non-adherent with their treatment plan. Almost all (94%) of homicides were committed by patients who had a history of alcohol or drug misuse and/or who were not in receipt of planned treatment. CONCLUSIONS: In England and Wales, homicides by patients with schizophrenia without substance misuse and in receipt of planned care are exceptionally rare. To prevent serious violence, mental health services should focus on drug and alcohol misuse, treatment adherence and maintaining contact with services.

Early Post-Discharge Suicide in Mental Health Patients: Findings From a National Clinical Survey.

Studies on suicide by recently discharged mental health patients have reported a high number of deaths in the early post-discharge period, which has led to recommendations of follow-up within 7 days (d). More recently, the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) proposed a more "stringent" follow-up period of 2-3 days (d) after discharge. Patients who died within this early time-frame post-discharge were more likely to die before the follow-up appointment occurred. They more often had a primary diagnosis of a personality disorder, self-discharged, and had a higher frequency of death by jumping from a height or in front of the vehicle compared to later deaths. This study provides practical implications for post-discharge management and safety planning. Clinicians should be aware of (1) the increased risk of immediate suicide in the post-discharge period by people with a diagnosis of personality disorder, (2) immediate suicide risk in patients who initiate their own discharge, and (3) the increased risk of death by jumping from a height or in front of the vehicle in the immediate post-discharge period. Our findings support the recent recommendation from NCISH that follow-up should occur within 3 d of discharge from in-patient care.

Examining the mechanisms by which adverse life events affect having a history of self-harm, and the protective effect of social support.

BACKGROUND: Psychological models of suicide emphasize perceptions of negative stressors, hopelessness and self-harm as key antecedents to suicidal thoughts/acts. Such models also emphasize the potential protective role of social support in these pathways. However, such pathways have not been tested using population level data. Hence, this study aimed to redress this gap. METHODS: Questionnaire data regarding 24,444 patient suicide deaths were analysed. All individuals died between 1996 and 2015 and were seen by secondary mental health services in England within 12 months before their death. Mediation analyses, using fitted logistic regression models, investigated direct and indirect pathways between negative stressors, hopelessness and a proxy measure of suicide, namely, self-harm history. In addition, the buffering effects of social support were examined in these pathways. RESULTS: There was a direct effect of negative life events on suicidal behaviors. Supporting contemporary psychological models of suicide, a mediated effect via hopelessness and a protective effect of social support were identified. Social support buffered the pathway between stressful life events and hopelessness, with hopelessness decreasing as social support increased. LIMITATIONS: Causal inferences are inappropriate as the design was cross-sectional. A proxy measure of suicidality was utilized (history of self-harm) as all individuals had died by suicide. CONCLUSIONS: This is the first time that population data has been used to test psychological pathways to suicidal acts involving negative stressors, hopelessness and social support. Psychological interventions should focus on increasing social support following negative life events together with ameliorating perceptions of hopelessness.

Suicide risk assessment in UK mental health services: a national mixed-methods study.

BACKGROUND: Risk assessments are a central component of mental health care. Few national studies have been done in the UK on risk assessment tools used in mental health services. We aimed to examine which suicide risk assessment tools are in use in the UK; establish the views of clinicians, carers, and service users on the use of these tools; and identify how risk assessment tools have been used with mental health patients before suicide. METHODS: We did a mixed-methods study involving three components: collection and content analysis of risk assessment tools used by UK mental health services; an online survey of clinicians, service-users, and carers; and qualitative telephone interviews with clinicians on their use of risk assessment tools before a suicide death and their views of these tools. The online survey was advertised through the National Confidential Inquiry into Suicide and Safety in Mental Health's (NCISH) website and social media, and it included both quantitative and open-ended qualitative questions, and respondents were recruited through convenience sampling. For the telephone interviews, we examined the NCISH database to identify clinicians who had been responsible for the care of a patient who died by suicide and who had been viewed as being at low or no immediate risk of suicide. FINDINGS: We obtained 156 risk assessment tools from all 85 National Health Service mental health organisations in the UK, and 85 (one per each organisation) were included in the analysis. We found little consistency in use of these instruments, with 33 (39%) of 85 organisations using locally developed tools. Most tools aimed to predict self-harm or suicidal behaviour (84 [99%] of 85), and scores were used to determine management decisions (80 [94%]). Clinicians described positive aspects of risk tools (facilitating communication and enhancing therapeutic relationships) but also expressed negative views (inadequate training in the use of tools and their time-consuming nature). Both patients and carers reported some positive views, but also emphasised little involvement during risk assessment, and a lack of clarity on what to do in a crisis. INTERPRETATION: Assessment processes need to be consistent across mental health services and include adequate training on how to assess, formulate, and manage suicide risk. An emphasis on patient and carer involvement is needed. In line with national guidance, risk assessment should not be seen as a way to predict future behaviour and should not be used as a means of allocating treatment. Management plans should be personalised and collaboratively developed with patients and their families and carers. FUNDING: The Healthcare Quality Improvement Partnership.

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 pacts in the mentally ill: a national clinical survey.

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