Clinical characteristics and care pathways of patients with personality disorder who died by suicide.

BACKGROUND: It is estimated that 1 in 10 people have a personality disorder. People with emotionally unstable personality disorder are at high risk of suicide. Despite being frequent users of mental health services, there is often no clear pathway for patients to access effective treatments. AIMS: To describe the characteristics of patients with personality disorder who died by suicide, examine clinical care pathways and explore whether the care adhered to National Institute for Health and Care Excellence guidance. METHOD: National consecutive case series (1 January 2013 to 31 December 2013). The study examined the health records and serious incident reports of patients with personality disorder who died by suicide in the UK. RESULTS: The majority had a diagnosis of borderline/emotionally unstable or antisocial personality disorder. A high proportion of patients had a history of self-harm (n = 146, 95%) and alcohol (n = 101, 66%) or drug misuse (n = 79, 52%). We found an extensive pattern of service contact in the year before death, with no clear pathway for patients. Care was inconsistent and there were gaps in service provision. In 99 (70%) of the 141 patients with data, the last episode of care followed a crisis. Access to specialised psychological therapies was limited; short-term in-patient admissions was adhered to; however, guidance on short-term prescribing for comorbid conditions was not followed for two-thirds of patients. CONCLUSIONS: Continuity and stability of care is required to prevent, rather than respond to individuals in crisis. A comprehensive audit of services for people with personality disorder across the UK is recommended to assess the quality of care provided.

It never rained in the house of sleep .

Night - bat black, brooding, all encompassing darkness, blanketing the colours of the day; the outlines blur and shapes become fluid.

Suicide in later life: a comparison between cases with early-onset and late-onset depression.

BACKGROUND: Suicide rates are high in elderly people with depressive disorder. We compared behavioural, clinical and care characteristics of depressed elderly patients, aged 60years and over at the time of death by suicide, with an early-onset depression (EOD, onset before 60years) with those patients with a late age of onset (LOD). METHOD: From a 10-year national clinical survey of all suicides in England and Wales (n=13066) we identified 549 LOD cases, and 290 EOD cases. EOD and LOD cases were compared by logistic regression adjusted for age at suicide. RESULTS: Method of suicide did not differ by age of onset of depression. LOD cases were significantly less likely to have a history of psychiatric admissions (OR=0.2 [0.1-0.3]), alcohol misuse (OR=0.6 [0.4-0.9]) and self-harm (0.6 [0.4-0.8]). LOD cases also had a lower prevalence of a psychiatric co-morbid diagnosis (0.6 [0.4-0.7]) and a lower prescription rate for psychotropic drugs other than antidepressants. Furthermore, the number of recent life-events was significantly higher (OR=1.4 [1.0-1.9]) in LOD while the frequency of recent self-harm was similar to EOD. CONCLUSION: Although our study suggests that psychopathology of suicide among elderly depressed patients differs between EOD and LOD, the final pathway (via recent self-harm) to suicide may be similar in up to a quarter of patients in both groups. Our results suggest that strategies to enhance coping abilities and provision of support to negate the effects of life-events might be especially important in the prevention of suicide in LOD.

Birthday blues: examining the association between birthday and suicide in a national sample.

BACKGROUND: Socioculturally meaningful events have been shown to influence the timing of suicide, but the influence of psychiatric disorder on these associations has seldom been studied. AIMS: To investigate the association between birthday and increased risk of suicide in the general population and in a national sample of psychiatric patients. METHODS: Data on general population suicides and suicide by individuals in recent care of mental health services were examined for day of death in relation to one's birthday using Poisson regression analysis. RESULTS: An increased risk of suicide was observed on day of one's birthday itself for males in both the general population (IRR = 1.39, 95% CI = 1.18-1.64, p < .01) and the clinical population (IRR = 1.48, 95% CI = 1.07-2.07, p = .03), especially for those aged 35 years and older. In the clinical population, risk was restricted to male patients aged 35-54 and risk extended to the 3 days prior to one's birthday. CONCLUSIONS: Birthdays are periods of increased risk for men aged 35 and older in the general population and in those receiving mental health care. Raising health-care professionals' awareness of patient groups at greater risk at this personally significant time may benefit care planning and could facilitate suicide prevention in these individuals.

Nonresident suicides in England: a national study.

Little is known about the numbers and characteristics of people who travel away from home before dying by suicide. Therefore, this studied attempts to identify the sociodemographic characteristics, location, and method of suicide in people who died distant from home, in a national sample. Data were collected on all English suicides and a patient population; nonresident suicides resided in one Health Authority but died in a different one. Twelve percent of suicides were nonresident and features of these included: young age, social adversity, and severe mental illness. In conclusion, both individual- and area-based factors are likely to contribute to suicide away from home.

Suicide prevention in primary care: General practitioners' views on service availability.

BACKGROUND: Primary care may be a key setting for suicide prevention. However, comparatively little is known about the services available in primary care for suicide prevention. The aims of the current study were to describe services available in general practices for the management of suicidal patients and to examine GPs views on these services. We carried out a questionnaire and interview study in the North West of England. We collected data on GPs views of suicide prevention generally as well as local mental health service provision. FINDINGS: During the study period (2003-2005) we used the National Confidential Inquiry Suicide database to identify 286 general practitioners (GPs) who had registered patients who had died by suicide. Data were collected from GPs and practice managers in 167 practices. Responses suggested that there was greater availability of services and training for general mental health issues than for suicide prevention specifically. The three key themes which emerged from GP interviews were: barriers accessing primary or secondary mental health services; obstacles faced when referring a patient to mental health services; managing change within mental health care services CONCLUSIONS: Health professionals have an important role to play in preventing suicide. However, GPs expressed concerns about the quality of primary care mental health service provision and difficulties with access to secondary mental health services. Addressing these issues could facilitate future suicide prevention in primary care.

Primary care contact prior to suicide in individuals with mental illness.

BACKGROUND: Previous studies have reported differing rates of consultation with GPs prior to suicide. Patients with a psychiatric history have higher rates of consultation and consult closer to the time of their death. AIM: To investigate the frequency and nature of general practice consultations in the year before suicide for patients in current, or recent, contact with secondary mental health services. DESIGN OF STUDY: Retrospective case-note study and semi-structured interviews. SETTING: General practices in the northwest of England. METHOD: General practice data were obtained by a retrospective review of medical records (n = 247) and semi-structured interviews with GPs (n = 159). RESULTS: GP records were reviewed in 247 of the 286 cases (86%). Overall, 91% of individuals (n = 224) consulted their GP on at least one occasion in the year before death. The median number of consultations was 7 (interquartile range = 3-10). Interviews were carried out with GPs with regard to 159 patients. GPs reported concerns about their patient's safety in 43 (27%) cases, but only 16% of them thought that the suicide could have been prevented. Agreement between GPs and mental health teams regarding risk of suicide was poor. Both sets of clinicians rated moderate to high levels of risk in only 3% of cases for whom information was available (n = 139) (overall kappa = 0.024). CONCLUSION: Consultation prior to suicide is common but suicide prevention in primary care is challenging. Possible strategies might include examining the potential benefits of risk assessment and collaborative working between primary and secondary care.