Implementation of mental health service recommendations in England and Wales and suicide rates, 1997-2006: a cross-sectional and before-and-after observational study.

BACKGROUND: Research investigating which aspects of mental health service provision are most effective in prevention of suicide is scarce. We aimed to examine the uptake of key mental health service recommendations over time and to investigate the association between their implementation and suicide rates. METHODS: We did a descriptive, cross-sectional, and before-and-after analysis of national suicide data in England and Wales. We collected data for individuals who died by suicide between 1997 and 2006 who were in contact with mental health services in the 12 months before death. Data were obtained as part of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. When denominator data were missing, we used information from the Mental Health Minimum Data Set. We compared suicide rates for services implementing most of the recommendations with those implementing fewer recommendations and examined rates before and after implementation. We stratified results for level of socioeconomic deprivation and size of service provider. FINDINGS: The average number of recommendations implemented increased from 0·3 per service in 1998 to 7·2 in 2006. Implementation of recommendations was associated with lower suicide rates in both cross-sectional and before-and-after analyses. The provision of 24 h crisis care was associated with the biggest fall in suicide rates: from 11·44 per 10 000 patient contacts per year (95% CI 11·12-11·77) before to 9·32 (8·99-9·67) after (p<0·0001). Local policies on patients with dual diagnosis (10·55; 10·23-10·89 before vs 9·61; 9·18-10·05 after, p=0·0007) and multidisciplinary review after suicide (11·59; 11·31-11·88 before vs 10·48; 10·13-10·84 after, p<0·0001) were also associated with falling rates. Services that did not implement recommendations had little reduction in suicide. The biggest falls in suicide seemed to be in services with the most deprived catchment areas (incidence rate ratio 0·90; 95% CI 0·88-0·92) and the most patients (0·86; 0·84-0·88). INTERPRETATION: Our findings suggest that aspects of provision of mental health services can affect suicide rates in clinical populations. Investigation of the relation between new initiatives and suicide could help to inform future suicide prevention efforts and improve safety for patients receiving mental health care. FUNDING: National Patient Safety Agency, UK.

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.

Trends in rates of mental illness in homicide perpetrators.

BACKGROUND: The rise in homicides by those with serious mental illness is of concern, although this increase may not be continuing. AIMS: To examine rates of mental illness among homicide perpetrators. METHOD: A national consecutive case series of homicide perpetrators in England and Wales from 1997 to 2006. Rates of mental disorder were based on data from psychiatric reports, contact with psychiatric services, diminished responsibility verdict and hospital disposal. RESULTS: Of the 5884 homicides notified to the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness between 1997 and 2006, the number of homicide perpetrators with schizophrenia increased at a rate of 4% per year, those with psychotic symptoms at the time of the offence increased by 6% per year. The number of verdicts of diminished responsibility decreased but no change was found in the number of perpetrators receiving a hospital order disposal. The likeliest explanation for the rise in homicide by people with psychosis is the misuse of drugs and/or alcohol, which our data show increased at a similar magnitude to homicides by those with psychotic symptoms. However, we are unable to demonstrate a causal association. Although the Poisson regression provides evidence of an upward trend in homicide by people with serious mental illness between 1997 and 2006, the number of homicides fell in the final 2 years of data collection, so these findings should be treated with caution. CONCLUSIONS: There appears to be a concomitant increase in drug misuse over the period, which may account for this rise in homicide. However, an increase in the number of people in contact with mental health services may suggest that access to mental health services is improving. Previous studies have used court verdicts such as diminished responsibility as a proxy measure of mental disorder. Our data indicate that this does not reflect accurately the prevalence of mental disorder in this population.

Comparison of British national newspaper coverage of homicide committed by perpetrators with and without mental illness.

OBJECTIVE: Adverse newspaper reporting of mental illness and in particular, violence committed by a mentally ill person, is thought to contribute to stigma. However, violent events are also considered highly newsworthy by journalists. The aim of this study was to compare the likelihood of newspaper reporting for convicted perpetrators of homicide with and without a history of contact with mental health services. METHOD: A 12 month (April 2000-March 2001) cohort of 577 homicide perpetrators with and without a history of contact with mental health services in England and Wales was examined. These cases were identified by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. By examining 12 national newspapers, we compared the likelihood of reporting homicide perpetrators with and without mental illness. RESULTS: Under half (228 cases, 40%) of the homicide perpetrators were reported in at least one of the study newspapers. Under a fifth (94 cases, 16%) of perpetrators had a history of contact with mental health services and such previous contact did not increase the likelihood of newspaper reporting (odds ratio 1.0 (0.6-1.6)). CONCLUSIONS: Previous contact with mental health services did not influence the newsworthiness of a homicide perpetrator. The stigmatizing effect of reporting homicide by perpetrators with mental illness may relate more to the quality of reporting rather than selective over-reporting.

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.

The timing of general population and patient suicide in England, 1997-2012.

BACKGROUND: There have been conflicting findings on temporal variation in suicide risk and few have examined the phenomenon in clinical populations. The study investigated seasonal and other temporal patterns using national data. METHODS: Data on 73,591 general population and 19,318 patient suicide deaths in England between 1997 and 2012 were collected through the National Confidential Inquiry into Suicide examining suicide rates in relation to month of the year, day of the week, and individual days of national or religious significance. RESULTS: Suicide incidence fell over successive months of the year and there was evidence of an overall spring peak. Monday was associated with the highest suicide rates and in the patient population this effect appeared to be more pronounced in those aged over 50 or those who lived alone. Suicide risk was significantly lower during Christmas, particularly for women. There was a peak in suicide on New Year's Day in the general population. Other 'special days' were not associated with a change in suicide incidence. LIMITATIONS: We were limited to identifying associations between the variables investigated and were unable to explore causal mechanisms. We did not carry out comprehensive multi-variable adjustment in our regression models. CONCLUSIONS: There is substantial seasonal and temporal variation in suicide deaths, and there appears to be some evidence in the clinical as well as the general population in England. Clinical services should be aware of the risk of suicide just after the weekend, especially in people who live alone, and the potential need for closer supervision during this period.