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Homicide rates have fallen markedly in the UK over the past decade. There has been little research on whether homicides by people with mental disorder have contributed to this downward trend. Furthermore, there is limited information on trends in court outcomes for people with mental disorder who commit homicide.
To examine trends in general population homicide and homicide by people with mental disorder, and to explore court outcome.
We conducted a national, consecutive case series of homicide in England and Wales (1997–2015). Data were received from the Home Office Statistics Unit of Home Office Science. Clinical information was obtained from psychiatric reports and mental health services.
There has been a fall in the homicide rate in England and Wales since 2008. Despite this, the relative contribution of mental disorder as a proportion of all homicide has increased. Our findings also showed the inappropriate management of people with serious mental illness convicted of homicide. Of those who committed homicide and were diagnosed with schizophrenia, a third were imprisoned, and there was a marked fall in hospital order referrals. We found this to be linked to substance misuse comorbidity.
The proportional increase in homicide by people with schizophrenia suggests more complex factors may be driving rates, such as substance misuse. Addressing substance misuse comorbidity and maintaining engagement with services may help prevent patient homicide. Despite their complex needs, people with serious mental illness continue to be imprisoned. Improvements in assessment and the timely transfer of prisoners to health services are required.
Individual- and area-level risk factors for suicide are relatively well-understood but the role of macro social factors such as alienation, social fragmentation or ‘anomie’ is relatively underresearched. Voting choice in the 2016 referendum on the UK's membership of the European Union (EU) provides a potential measure of anomie.
To examine associations between percentage ‘Leave’ votes in the EU referendum and suicide rates in 2015–2017, the period just prior to, and following, the referendum.
National cross-sectional ecological study of 315 English local authority populations. Associations between voting choice in the EU referendum and age-standardised suicide rates, averaged for the years 2015, 2016 and 2017, were examined.
Overall there was a weak, but statistically significant, positive correlation between the local authority-level percentage ‘Leave’ vote in 2016 and the suicide rate 2015–2017: Pearson's correlation coefficient, r = 0.17; P = 0.003. This relationship was explained by populations having an older age distribution, being more deprived and lacking ethnic diversity. However, there was divergence (likelihood ratio test for interaction, χ2 = 7.2, P = 0.007) in the observed associations between London and the provincial regions with Greater London having a moderately strong negative association (r = −0.40; P = 0.02) and the rest of England a weak positive association (r = 0.17; P = 0.004).
Deprivation, older age distribution and a lack of ethnic diversity seems to explain raised suicide risk in Brexit-voting communities. A greater sense of alienation among people feeling ‘left behind’/‘left out’ may have had some influence too, although multilevel modelling of individual- versus area-level data are needed to examine these complex relationships. The incongruent ecological relationship observed for London likely reflect its distinct social, economic and health context.
Worldwide suicide is commonest in young people and in many countries, including the UK, suicide rates in young people are rising.
To investigate the stresses young people face before they take their lives, their contact with services that could be preventative and whether these differ in girls and boys.
We identified a 3-year UK national consecutive case series of deaths by suicide in people aged 10–19, based on national mortality data. We extracted information on the antecedents of suicide from official investigations, primarily inquests.
Between 2014 and 2016, there were 595 suicides by young people, almost 200 per year; 71% were male (n = 425). Suicide rates increased from the mid-teens, most deaths occurred in those aged 17–19 (443, 74%). We obtained data about the antecedents of suicide for 544 (91%). A number of previous and recent stresses were reported including witnessing domestic violence, bullying, self-harm, bereavement (including by suicide) and academic pressures. These experiences were generally more common in girls than boys, whereas drug misuse (odds ratio (OR) = 0.54, 95% CI 0.35–0.83, P = 0.006) and workplace problems (OR 0.52, 95% CI 0.28–0.96, P = 0.04) were less common in girls. A total of 329 (60%) had been in contact with specialist children's services, and this was more common in girls (OR 1.86, 95% CI 1.19–2.94, P = 0.007).
There are several antecedents to suicide in young people, particularly girls, which are important in a multiagency approach to prevention incorporating education, social care, health services and the third sector. Some of these may also have contributed to the recent rise.
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.
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.
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.
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.
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.
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.
To investigate suicide trends related to the recession in mental health patients in England.
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.
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.
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 interest
N.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.
In England suicide rates are highest in midlife (defined as age 40–59). Despite a strong link with suicide there has been little focus on self-harm in this age group.
To describe characteristics and treatment needs of people in midlife who present to hospital following self-harm.
Data from the Multicentre Study of Self-harm in England were used to examine rates over time and characteristics of men and women who self-harm in midlife. Data (2000–2013) were collected via specialist assessments or hospital records. Trends were assessed by negative binomial regression models. Comparative analysis used logistic regression models for binary outcomes. Repetition and suicide mortality were assessed by Cox proportional hazards models.
A quarter of self-harm presentations were made by people in midlife (n = 24 599, 26%). Incidence rates increased over time in men, especially after 2008 (incidence rate ratio [IRR] 1.07, 95% CI 1.02–1.12, P < 0.01), and were positively correlated with national suicide incidence rates (r = 0.52, P = 0.05). Rates in women remained relatively stable (IRR 1.00, 95% CI 1.00–1.02, P = 0.39) and were not correlated with suicide. Alcohol use, unemployment, housing and financial factors were more common in men; whereas indicators of poor mental health were more common in women. In men and women 12-month repetition was 25%, and during follow-up 2.8% of men and 1.2% of women died by suicide.
Self-harm in midlife represents a key target for intervention. Addressing underlying issues, alcohol use and economic factors may help prevent further self-harm and suicide.
Declaration of interest
K.H. and N.K. are members of the Department of Health's National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group which developed the quality standards for self-harm services. N.K. also chairs the NICE guideline committee for the management of depression. All other authors declare no conflict of interest.
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.
To investigate the timing of suicide in high-risk mental health patients.
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).
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.
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.
Recent years have seen a substantial increase in the use of crisis resolution home treatment (CRHT) teams as an alternative to psychiatric in-patient admission. We discuss the functions of these services and their effectiveness. Our research suggests high rates of suicide in patients under CRHT. Specific strategies need to be developed to improve patient safety in this setting.
The elevated risk of suicide in prison and after release is a well-recognised and serious problem. Despite this, evidence concerning community-based offenders' suicide risk is sparse. We conducted a population-based nested case–control study of all people in a community justice pathway in England and Wales. Our data show 13% of general population suicides were in community justice pathways before death. Suicide risks were highest among individuals receiving police cautions, and those having recent, or impending prosecution for sexual offences. Findings have implications for the training and practice of clinicians identifying and assessing suicidality, and offering support to those at elevated risk.
This paper reviews the major organisational changes made to the delivery of mental healthcare in prisons in England and Wales since the turn of the century. These changes have included the introduction of ‘in-reach’ services for prisoners with serious mental illness, replicating the work of community mental health teams. In addition, healthcare budgets and commissioning responsibilities have been transferred to the National Health Service. Measures to reduce the rate of suicide in prisons are also considered.
Risk of self-harm and suicide is greatly increased in the period after
discharge from psychiatric in-patient care.
To investigate the impact on suicide of a series of policy initiatives to
enhance care in the immediate post-discharge period.
A time series analysis was based on 1997–2007 data from the National
Confidential Inquiry into Suicide and from Hospital Episode Statistics
There was no evidence of a reduced risk of suicide in the first 12 weeks
following discharge in 2003–2007 compared with 1997–2002. In contrast,
the relative risk of non-fatal self-harm in the 12 weeks after discharge
declined. The risk ratio for self-harm (2003–2007 v.
1997–2002) at 0–1 week post-discharge was 0.86 (95% CI 0.80–0.92) and at
2–4 weeks it was 0.89 (95% CI 0.85–0.94).
These findings provide some support for the impact of recent policy
changes on the risk of non-fatal self-harm in the immediate period after
discharge from psychiatric in-patient care.
The global economic downturn seems to be associated with a rise in suicide rates in many countries but we should not assume that this is a social rather than a clinical phenomenon. Mental health patients may be particularly vulnerable to unemployment and other hardships and to cuts in the care they receive. There is now no shortage of evidence on how clinical services and health policies can reduce suicide, and in England a new suicide prevention strategy was recently launched for public consultation. What we lack is an effective forum where a rigorous examination of international evidence can take place, with the findings translated into actions.
Suicide rates in Scotland have increased markedly relative to those in England in recent decades.
To compare changing patterns of suicide risk in Scotland with those in England & Wales, 1960–2008.
For Scotland and for England & Wales separately, we obtained national data on suicide counts and population estimates. Gender-specific, directly age-standardised rates were calculated.
We identified three distinct temporal phases: 1960–1967, when suicide rates in England & Wales were initially higher than in Scotland, but then converged; 1968–1991, when male suicide rates in Scotland rose slightly faster than in England & Wales; and 1992–2008, when there was a marked divergence in national trends. Much of the recent divergence in rates is attributable to the rise in suicide among young men and deaths by hanging in Scotland. Introduction of the ‘undetermined intent’ category in 1968 had a significant impact on suicide statistics across Great Britain, but especially so in Scotland.
Differences in temporal patterns in suicide risk between the countries are complex. Reversal of the divergent trends may require a change in the perception of hanging as a ‘painless' method of suicide.
The rise in homicides by those with serious mental illness is of concern,
although this increase may not be continuing.
To examine rates of mental illness among homicide perpetrators.
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.
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.
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
Offender health is an important part of general mental healthcare. To improve the health of offenders, we need reforms similar to the reforms in community care of the last decade – early intervention, alternatives to the institution and multi-agency community services. Front-line clinicians are in a key position to bring about such reforms. It will be crucial to argue that improvements in offender health will help bring about broader government aims such as reduced reoffending.