Louis Appleby Professor of Psychiatry University of Manchester Chair, National Suicide Prevention...

Louis Appleby Professor of Psychiatry

University of Manchester

Chair, National Suicide Prevention Advisory Group

Department of Health

National Suicide Prevention Strategy: Six actions

• Reduce risk in high risk groups • Tailor approaches to improve mental health in

specific groups• Reduce access to the means of suicide • Provide better information and support to those

bereaved or affected by suicide • Support media in delivering sensitive approaches

to suicide• Support research, data collection and monitoring

Suicide rates, England 1994-2012

Age standardised death rate per 100,000 population

Source: ONS

3-year average

Suicide rates by age and gender, England 2012

Source: ONS

Suicide in young men

0

5

10

15

20

25

30

1973 1978 1983 1988 1993 1998 2003 2008

Age standardised death rateper 100,000 population

Males 20-34

Persons, All Ages

Three-year average rate, plotted against final year of average

Males 35-49

Source: ONS

2010

UK(1996-2012)

England(1996-2012)

Wales(1996-2012)

Scotland(1997-2012)

N. Ireland(1997-2012)

N N N N N

Generalpopulation

100,329 78,170 5,475 13,235 3,449

In contact withservices

26,216(26%)

20,300(26%)

1,260(23%)

3,705(28%)

951(28%)

National Confidential Inquiry: suicides

Patient suicides: age and gender profile

7%

18%

27%

22%

14%

7%

5%7%

14%

22%23%

18%

10%7%

0

500

1000

1500

2000

2500

Under 25 25-34 35-44 45-54 55-64 65-74 75+

Nu

mb

er o

f p

atie

nts

Age-group

Male Female

ENGLAND_SUICIDE (2002-2012)© National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved.Not to be reproduced in whole or part without the permission of the copyright holder.

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

200

400

600

800

1000

1200

1400

1250 1256

13171277

1123 1139

1209

11541227

1215

771

1272

Estimated Confirmed

Year

Nu

mb

er

of

pa

tie

nts

130713061242761234

Patient suicide - England



Patient suicide method - England

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

100

200

300

400

500

600

700

456 456

515487

456 472

549

479

584556

615

336345

379

339

272281 289

328 326

372

332

198 210182 192

206 198 198217

182160

144

Hanging/strangulation Self-poisoning Jumping/multiple injuries

Year

Nu

mb

er o

f p

atie

nts

Patient suicides: primary diagnosis by gender


Living circumstances: patient suicides

Alone 5768 (46%)

With parent(s)1435 (11%)

With spouse/partner (with or without

children)3793 (30%)

With children only555 (4%)

Other shared (e.g. friends)

651 (5%)

Prison/YOI70 (1%)

Other specified310 (2%)


Timing of last contact: patient suicides

18%

32%

22%

13%14%

0

500

1000

1500

2000

2500

3000

3500

4000

4500

< 24 hours 1-7 days 1-4 weeks 5-13 weeks More than 13weeks

Nu

mb

er o

f p

atie

nts


Mental health teams’ estimation of suicide risk at last contact: patient suicides

12%

48%

31%

9%

28%

58%

12%

2%0

1000

2000

3000

4000

5000

6000

7000

8000

No risk Low Moderate High

Nu

mb

er o

f pat

ien

ts

Suicide risk

Long-term risk Immediate risk


UK(1996-2012)

N

England(1996-2012)

N

Wales(1996-2012)

N

Scotland(1997-2012)

N

N. Ireland(1997-2012)

N

Generalpopulation

10,974 8,959 416 1,329 270

In contact withservices

1,133(10%)

866(10%)

44(11%)

191(14%)

32(12%)

Homicide convictions

UK_HOMICIDE © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved.Not to be reproduced in whole or part without the permission of the copyright holder.

Primary diagnosis of patient homicides (based on Inquiry questionnaire data)

ENGLAND_HOMICIDE (2002-2012)© National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved.Not to be reproduced in whole or part without the permission of the copyright holder.

Other

Personality disorder

Drug dependence/misuse

Alcohol dependence/misuse

Affective disorder

Schizophrenia and other delusional disorders

0 20 40 60 80 100 120 140 160 180

11%

16%

16%

13%

13%

30%

Number of patients

Secondary diagnosis of patient homicides (based on Inquiry questionnaire data)


Other

Dementia

Anxiety/phobia/panic disorder/OCD

ADHD/conduct disorder

Pervasive development disorder/autistic

Learning disability

Organic disorder

Adjustment disorder/reaction

Personality disorder

Drug dependence/misuse

Alcohol dependence/misuse

Affective disorder

0 20 40 60 80 100 120

1%

1%

5%

1%

1%

1%

1%

4%

17%

30%

25%

17%

Number of patients

Mental health teams’ estimation of risk of violence at last contact: patient homicides


No risk Low Moderate High0

50

100

150

200

250

33%

38%

22%

7%

48%

42%

8%

1%

Long-term risk

Immediate risk

Risk of violence

Nu

mb

er o

f p

atie

nts


2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

10

20

30

40

50

60

70

80

44

7064

72 74

53

66

38 37 36

22

59

71

44 4347

44

Estimated Confirmed

Year of conviction

Num

ber o

f pati

ents

Patient homicide - England

• Study of “low risk paradox”

• Case note review of 81 patient suicides/homicides

• Conclusion: risk management should be individual to patient

Patient suicide: number of mental health in-patients; number who died by hanging/strangulation on the ward


2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

20

40

60

80

100

120

140

160

180

200

165

183

162155

142

122

106 103

8983

50

36

46

3428 31

20 2028 23

14 15

In-patient suicide Hanging/strangulation on the ward

Year

Nu

mb

er o

f p

atie

nts

In-patient suicides – care factors

• less likely to be detained under MHA (OR=0.43)

• more likely to be off ward without agreement (OR=13.07)

Source: Hunt et al, Psych Med, 2007

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

50

100

150

200

250

59

71

108

153

156

177190

223

185 185

149

165

183

162 155

142 122

106103

8983

50

CR/HT In-patient

Year

Nu

mb

er o

f p

atie

nts

Suicide under CR/HT and in-patient care - England


Suicide under crisis resolution/home treatment teams

• 140 suicides per year (England 2003-11)

• Rate higher than among in-patients(14.6 per 10,000 CR/HT episodes vs. 8.8 per 10,000 admissions)

• Increase from 80 per year (2003-04) to 163 (2010-11)

• Rate has fallen

• 44% lived alone; 49% adverse life events; 34% died <3 months discharge

SOURCE: NCI data, Lancet Psychiatry (2014)

Suicides per week following discharge, England


1 2 3 4 5 6 7 8 9 10 11 12 130

50

100

150

200

250

300

350

400 380

292

253

207 199

161147

134 137122 113 111 123

Weeks between discharge and suicide (Week 1 = First week following discharge)

Nu

mb

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of

pa

tie

nts

Suicide within two weeks of hospital discharge

• Case-control study 100 post-discharge suicides and 100 living controls (England 2004-06)

• Independent risk factors:

self-harmmale gender aged ≥ 40last admission <7 daysadverse life eventsco-morbid psychiatric illness

• Under CPA protective

SOURCE: NCI data, Psychiatric Services (2013)

Mental health teams contact with relatives after suicide: patient suicides

None3674 (32%)

Letter862 (8%)

Discussion (face to face or

telephone)6859 (60%)

Other78 (1%)


Patients as victims of homicide

• 1,496 victims (England & Wales, 2003-05)

• 90 (6%) patient victims

• 29/90 killed by fellow patient (7 with schizophrenia)

• 21/29 both victim and offender at the same NHS Trust

• Alcohol/drug misuse and previous violence common among patient victims and perpetrators

SOURCE: NCI data, Lancet Psychiatry (2014)

Key service recommendations

Removal of ligature points

Assertive outreach

24-hour crisis team

7-day follow-up

Non-compliance

Dual diagnosis

Criminal justice sharing

Multi-disciplinary review

Training in suicide risk management

Safety First, 200112 Steps to a Safer Service

Do safety measures reduce suicide rates?

Patient suicide rate per 10,000

*

* = significant difference p<0.05

Source: National Confidential Inquiry, Lancet, 2012

Suicide rates in target groups

Recommendation Target group % fall in suicide

Ligature points In-patients 24%

Assertive outreach ‘Non-compliant’ community patients 32%

Assertive outreach ‘Missed appointment’ community patients 11%

24-hour crisis team In-patients 29%

7-day follow-up Patients within 3 months of discharge 21%

Non-compliance ‘Non-compliant’ policy community patients 25%

Source: National Confidential Inquiry, Lancet, 2012

Patient suicide: the impact of service changes

Safety priorities for MH care

• Support for patients facing financial problems

• Review use of crisis resolution/home treatment

• Care plan & early follow-up post-hospital discharge

• Continue focus on ward environment

• Maintain specialised community teams: AO, dual diagnosis

• Multidisciplinary review after incidents

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Louis Appleby Professor of Psychiatry University of Manchester Chair, National Suicide Prevention...

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