The role of alcohol and drugs in homicides in England and Wales.

BACKGROUND: The annual number of homicide convictions in England and Wales is increasing. Previous studies have highlighted the aetiological role of alcohol and drugs in homicide. AIMS: To examine rates of alcohol and drug misuse and dependence in people convicted of homicide; the role of alcohol and drugs in the offence; the social and clinical characteristics of alcohol- and drug-related homicides; and the social and clinical characteristics of patients with dual diagnosis who commit homicide. METHODS: A national clinical survey based on a 3-year (1996-9) consecutive sample of people convicted of homicide in England and Wales. Information on rates of alcohol and drug misuse/dependence, the role of alcohol and drugs in the offence and social and clinical characteristics of perpetrators were collected from psychiatric reports prepared for the court in homicide convictions. Detailed clinical information was gathered from questionnaires completed by mental health teams for those in contact with mental health services. RESULTS: Of the 1594 homicide perpetrators, more than one-third (42%) occurred in people with a history of alcohol misuse or dependence and 40% in people with a history of drug misuse or dependence. Alcohol or drug misuse played a contributory role in two-fifths of homicides. Alcohol played a major role in 52 (6%) and a minor role in 364 (39%) homicides. Drugs played a major role in six (1%) and a minor role in 138 (14%) homicides. Forty-two homicides (17%) were committed by patients with severe mental illness and substance misuse. Alcohol- and drug-related homicides were generally associated with male perpetrators who had a history of violence, personality disorders, mental health service contact and with stranger victims. CONCLUSIONS: Substance misuse contributes to the majority of homicides in England and Wales. A public health approach to homicide would highlight alcohol and drugs before severe mental illness.

Perpetrators of homicide with schizophrenia: a national clinical survey in England and Wales.

OBJECTIVE: Few studies have described rates of schizophrenia in a national sample of homicide perpetrators. This study aimed to describe this group's social and clinical characteristics, mental state features, offense details, and outcome in court. METHOD: Analyses used a national clinical survey that collected data on people convicted of homicide in England and Wales (1996-1999). Data were collected for those with schizophrenia or other delusional disorders from psychiatric reports and questionnaires. RESULTS: Of the 1,594 people convicted of homicide, 85 (5 percent) had schizophrenia. Of the 57 people with schizophrenia for whom data were available, 32 (56 percent) had been ill for less than 12 months, and in the month before the offense, 32 (56 percent) had shown a change in the quality, intensity, or conviction of or emotional response to their delusional beliefs. Twenty-four (28 percent) had no previous contact with psychiatric services. CONCLUSIONS: Regular assessment of delusions may help to detect an increased risk of violence, including homicide. More intensive care should be available for patients with a history of schizophrenia and previous violence.

Suicide in the homeless within 12 months of contact with mental health services : a national clinical survey in the UK.

BACKGROUND: Suicide prevention is a health service priority. Homeless mental health patients present a challenge to services because of their complex health and social needs. AIMS: To establish the numbers of homeless patients in contact with services who die by suicide; to describe their suicide methods and their social and clinical characteristics including aspects of clinical care. METHOD: A national clinical survey based on a 4-year (1996-2000) sample of people in England and Wales who died by suicide. Detailed data were collected on those who had been in contact with mental health services in the year before death. RESULTS: A total of 131 individuals who died by suicide were reported to have been homeless at the time of death--3% of all suicides by psychiatric patients, over 30 per year. Hanging was the most common cause of death. The most frequent diagnosis was schizophrenia. Around half were in-patients at the time of death. Social and clinical risk factors for suicide were common, including drug and alcohol misuse, and recent suicidal ideas and behaviour. Despite this, their clinical care was characterised by disengagement from services as a result of missed contacts, self-discharge, lack of follow-up and lack of key worker. CONCLUSIONS: In order to reduce the number of deaths by suicide in those who are homeless and mentally ill, improvements in in-patient safety and engagement in the community are needed. This may be achieved through assertive community treatment, dual diagnosis services, and dedicated community mental health teams.

Suicide in mental health in-patients and within 3 months of discharge. National clinical survey.

BACKGROUND: Suicide prevention is a health service priority. Suicide risk may be greatest during psychiatric in-patient admission and following discharge. AIMS: To describe the social and clinical characteristics of a comprehensive sample of in-patient and post-discharge cases of suicide. METHOD: A national clinical survey based on a 4-year (1996-2000) sample of cases of suicide in England and Wales who had been in recent contact with mental health services (n=4859). RESULTS: There were 754 (16%) current in-patients and a further 1100 (23%) had been discharged from psychiatric in-patient care less than 3 months before death. Nearly a quarter of the in-patient deaths occurred within the first 7 days of admission; 236 (31%) occurred on the ward, the majority by hanging. Post-discharge suicide was most frequent in the first 2 weeks after leaving hospital; the highest number occurred on the first day. CONCLUSIONS: Suicide might be prevented among in-patients by improving ward design and removing fixtures that can be used in hanging. Prevention of suicide after discharge requires early community follow-up and closer supervision of high-risk patients.

Suicide within 12 months of mental health service contact in different age and diagnostic groups: National clinical survey.

BACKGROUND: Suicide prevention is a health service priority but the most effective approaches to prevention may differ between different patient groups. AIMS: To describe social and clinical characteristics in cases of suicide from different age and diagnostic groups. METHOD: A national clinical survey of a 4-year (1996-2000) sample of cases of suicide in England and Wales where there had been recent (<1 year) contact with mental health services (n=4859). RESULTS: Deaths of young patients were characterised by jumping from a height or in front of a vehicle, schizophrenia, personality disorder, unemployment and substance misuse. In older patients, drowning, depression, living alone, physical illness, recent bereavement and suicide pacts were more common. People with schizophrenia were often in-patients and died by violent means. About a third of people with depressive disorder died within a year of illness onset. Those with substance dependence or personality disorder had high rates of disengagement from services. CONCLUSIONS: Prevention measures likely to benefit young people include targeting schizophrenia, dual diagnosis and loss of service contact; those aimed at depression, isolation and physical ill-health should have more effect on elderly people.

Rates of mental disorder in people convicted of homicide. National clinical survey.

BACKGROUND: Previous studies of people convicted of homicide have used different definitions of mental disorder. AIMS: To estimate the rate of mental disorder in people convicted of homicide; to examine the relationship between definitions, verdict and outcome in court. METHOD: A national clinical survey of people convicted of homicide (n=1594) in England and Wales (1996-1999). Rates of mental disorder were estimated based on: lifetime diagnosis, mental illness at the time of the offence, contact with psychiatric services, diminished responsibility verdict and hospital disposal. RESULTS: Of the 1594,545 (34%) had a mental disorder: most had not attended psychiatric services; 85 (5%) had schizophrenia (lifetime); 164 (10%) had symptoms of mental illness at the time of the offence; 149 (9%) received a diminished responsibility verdict and 111 (7%) a hospital disposal - both were associated with severe mental illness and symptoms of psychosis. CONCLUSIONS: The findings suggest an association between schizophrenia and conviction for homicide. Most perpetrators with a history of mental disorder were not acutely ill or under mental healthcare at the time of the offence. Some perpetrators receive prison sentences despite having severe mental illness.

Clustering of suicides among people with mental illness.

BACKGROUND: Most previous investigations of imitative suicide have reported suicide clustering in the general population, either temporal clustering following media reporting of suicide or case studies of geographically localised clusters. AIMS: To determine whether space - time and space-time-method clustering occur in a national case register of those who had recent contact with mental health services and had died by suicide and to estimate the suicide imitation rate in this population. METHOD: Knox tests were used for space-time and space-time-method clustering. Model simulations were used to estimate effect size. RESULTS: Highly significant space-time and space-time-method clustering was found in a sample of 2741 people who died by suicide over 4 years who had had recent contact with one of 105 mental health trusts. Model simulations with an imitation rate of 10.1% (CI 4-17) reproduced the observed space-time-method clustering. CONCLUSIONS: This study provides indirect evidence that imitative suicide occurs among people with mental illnesses and may account for about 10% of suicides by current and recent patients.

Suicides in ethnic minorities within 12 months of contact with mental health services. National clinical survey.

BACKGROUND: Information on suicide by psychiatric patients from ethnic minority groups is scarce. AIMS: To establish the number of patients from ethnic minorities who kill themselves; to describe their suicide methods, and their social and clinical characteristics. METHOD: A national clinical survey was based on a 4-year sample of suicides in England and Wales. Detailed data were collected on those who had been in contact with mental health services in the year before death. RESULTS: In total 282 patients from ethnic minorities died by suicide--6% of all patient suicides. The most common method of suicide was hanging; violent methods were more common than in White patient suicides. Schizophrenia was the most common diagnosis. Ethnic minority patients were more likely to have been unemployed than White patients and to have had a history of violence and recent non-compliance. In around half, this was the first episode of self-harm. Black Caribbean patients had the highest rates of schizophrenia (74%), unemployment, living alone, previous violence and drug misuse. CONCLUSIONS: In order to reduce the number of suicides by ethnic minority patients, services should address the complex health and social needs of people with severe mental illness.