Transcript h - Centre for Recovery and Social Inclusion

Louis Appleby
Professor of Psychiatry
NCI ANNUAL REPORT 2013
© 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.
Suicide rates, England 1994-2012
Age standardised death rate per 100,000 population
Ages
3-year average
Source: ONS
Suicide rates by age and
gender, England 2012
Source: ONS
Suicide methods, England 2012
Source: ONS
Deaths mentioning helium poisoning,
England 2002-2012
Cause of death was defined using ICD-10 codes related to drug poisoning. Deaths were included where helium was
mentioned on the death certificate
Source: ONS
Suicide in young men
Age standardised death rate
per 100,000 population
Males 35-49
30
25
Persons, All Ages
20
Males 20-34
15
10
5
0
1973
1978
1983
1988
1993
1998
Three-year average rate, plotted against final year of average
Source: ONS
2003
2008
2010
Suicide rates in the general population,
UK country
England
Northern Ireland
Scotland
Wales
Suicide rate per 100,000 population
25
20
19.5
19.8
18.7
17.6
15.9
15
10
13.9
14.4
12.4
12.8
11.1
10.6
10.6
10.6
12.8
12.0
17.2
16.8
15.3
14.9
12.0
11.1
18.2
17.0
18.5
18.2
16.7
16.5
14.7
11.1
18.9
11.3
16.8
14.7
11.1
11.5
10.5
10.5
10.0
9.4
10.1
9.3
9.4
9.3
8.8
5
0
2001
2002
2003
2004
2005
2006
2007
Year
UK COMPARISONS (2001-2011)_SUICIDE_REPORT 2013
© 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.
2008
2009
2010
2011
Suicide rates in the general population, by
age-group and UK country (2001-2011)
England
Northern Ireland
Scotland
Wales
Suicide rate per 100,000 population
30
25
20
15
10
5
0
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
Age-groups
UK COMPARISONS (2001-2011)_SUICIDE_REPORT 2013
© 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.
60-64
65-69
70-74
75-79
80-84
85-89
90+
National Confidential Inquiry: suicides
UK
England
Wales
Scotland
N. Ireland
(1996-2012)
(1996-2012)
(1996-2012)
(1997-2012)
(1997-2012)
N
N
N
N
N
General
population
100,329
78,170
5,475
13,235
3,449
In contact with
services
26,216
(26%)
20,300
(26%)
1,260
(23%)
3,705
(28%)
951
(28%)
Patient suicides: cause of death by gender
Male
Female
4500
4000
45%
Number of suicides
3500
3000
2500
2000
22%
37%
1500
16%
30%
1000
15%
500
4%
10%
5%
8%
9%
1%
0
Hanging/strangulation
Self-poisoning
Carbon m onoxide
poisoning
Jum ping/m ultiple
injuries
Cause of death
ENGLAND_SUICIDE (2001-2011)
© 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.
Drow ning
Other
Patient suicides: primary diagnosis by
gender
Male
Female
4000
42%
3500
Number of suicides
3000
55%
2500
2000
20%
1500
10%
1000
7%
13%
12%
500
6%
5%
2%
0
Schizophrenia
Affective disorder
Personality
disorder
ENGLAND_SUICIDE (2001-2011)
© 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.
Alcohol
dependence
Drug
dependence
Living circumstances: patient suicides
Other shared
(e.g. friends)
651 (5%)
Prison/YOI
70 (1%)
Other specified
310 (2%)
With children only
555 (4%)
Alone
5768 (46%)
With spouse/partner
(w ith or w ithout
children)
3793 (30%)
With parent(s)
1435 (11%)
ENGLAND_SUICIDE (2001-2011)
© 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.
In-patient suicides – cause of death
Male
Female
500
450
49%
Number of suicides
400
350
300
28%
250
200
36%
26%
150
15%
100
8%
6%
50
2%
8%
10%
11%
1%
0
Hanging/strangulation
Self-poisoning
Carbon monoxide
poisoning
Jumping/multiple
injuries
Cause of death
ENGLAND_SUICIDE (2001-2011)
© 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.
Drow ning
Other
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
Number of in-patient suicides and
hangings on the ward (England 2001-2011)
In-patient suicide
200
183
179
180
165
162
160
Number of suicides
Hanging/strangulation on the ward
155
142
140
122
120
103
94
100
75
80
60
40
67
46
36
34
40
28
31
19
19
24
19
20
10
0
2001
2002
2003
2004
2005
2006
Year
2007
2008
2009
2010
2011
Number of suicides under CRHT and
mental health in-patients (England, 2003-2011)
CRHT
In-patient
250
190
Number of suicides
200
168
160
142
150
142
168
159
166
138
135
125
99
100
103
61
81
79
73
72
50
0
2003
2004
2005
2006
2007
Year of death
2008
2009
2010
2011†
Number of patient suicides per week
following discharge (2001-2011)
400
375
350
Number of suicides
300
284
253
250
217
194
200
165
136
150
144
139
125
118
114
117
10
11
12
13
100
50
0
1
2
3
4
5
6
7
8
9
Weeks between discharge and suicide
(Week 1 = First week following discharge)
ENGLAND_SUICIDE (2001-2011)
© 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.
Independent risk factors for suicide
within 2 weeks of discharge
OR
95% CI
Age >40
5.3
1.6-18.1
Male gender
3.1
1.1-8.9
Self-harm
6.8
2.1-21.8
Secondary diagnosis
4.4
1.2-15.4
Recent life events
4.6
1.5-14.2
Admission <1 week duration
3.4
1.1-10.3
Under CPA
0.3
0.1-0.8
Source: Bickley et al, Psychiatric Services, 2013
Timing of last contact: patient suicides
4500
31%
4000
Number of suicides
3500
22%
3000
2500
18%
2000
13%
14%
1500
1000
500
0
< 24 hours
1-7 days
1-4 weeks
ENGLAND_SUICIDE (2001-2011)
© 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.
5-13 weeks
More than 13
weeks
Mental health teams’ estimation of suicide
risk at last contact: patient suicides
Long-term risk
Immediate risk
8000
57%
Number of suicides
7000
6000
47%
5000
4000
31%
29%
3000
2000
12%
12%
1000
9%
2%
0
No risk
Moderate
Low
Suicide risk
ENGLAND_SUICIDE (2001-2011)
© 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.
High
Mental health teams contact with
relatives after suicide: patient suicides
Other
92 (1%)
None
3754 (32%)
Discussion
(face to face or
telephone)
6857 (59%)
ENGLAND_SUICIDE (2001-2011)
© 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.
Letter
872 (8%)
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, 2001
12 Steps to a Safer Service
Number of recommendations implemented
0 (none)
1
2
3
4
5
6
7
8
9 (all)
80
70
Number of Trusts
60
50
40
30
20
10
0
1998
1999
2000
2001
2002
Year
2003
2004
2005
2006
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
Ligature points
In-patients
24%
Assertive outreach
‘Non-compliant’
community patients
32%
‘Missed appointment’
community patients
11%
24-hour crisis team
In-patients
29%
7-day follow-up
Patients within 3
months of discharge
21%
‘Non-compliant’
community patients
25%
Assertive outreach
Non-compliance
policy
Source: National Confidential Inquiry, Lancet, 2012
% fall in suicide
Patient suicide: the impact of service
changes
Prison suicides: diagnosis
Any diagnosis
Of which:
Depression
Personality disorder
46%
Drug misuse
26%
Alcohol misuse
24%
35%
10%
Prison suicides: time since reception
Prison suicides: method 1999-2004
• 493 (93%) died by hanging
• 311 (61%) used bed-clothes as ligatures
• 251 (49%) used window bars
Case control study of prison suicide
Independent predictor
Adjusted Odds Ratio
P-value
(95% CI)
History of self-harm
5.03 (2.52-10.05)
<0.001
Occupying a single cell
3.70 (2.00-6.86)
<0.001
Remand status
3.28 (1.49-7.21)
0.003
Previous service contact
2.38 (1.24-4.54)
0.009
Prison suicides: prevention
• safe cells
• reception screening and referral
• early observation
• treatment of mental illness and substance
misuse
• care plans
Deaths in prison, England & Wales
Source: MoJ
Suicide after prison release
90
80
70
60
No. suicides 50
40
30
20
10
0
1
2
3
4
5
6
7
8
9
10 11 12 13
Time from release (28 day periods)
Source: Pratt et al, Lancet 2006
Criminal justice history and suicide
12
11
10
9
Odds
ratio
8
7
6
5
4
3
2
1
0
11.34
8.88
5.5
5.33
4.81
3.84
3.31
3.05
2.27
Any verdict
2.05
Custodial
sentence
Source: Webb et al, Arch Gen Psychiatry, 2011
Fined
Charges
withdrawn
Acquitted
Males
Females
Offence type and suicide
9
8.4
8
7
Odds
ratio
6
5
4
4.62
3.75
4.48
4.41
Males
3.75
2.8
3
2.94
2.13
2
1
0
0
Sexual
Violent
Source: Webb et al, Arch Gen Psychiatry, 2011
Property
Traffic
All other
offences
Females
Time since CJS contact and suicide
7
6.39
6
5
Odds
ratio
5.72
5.43
4.95
3.9
4
3.74
3.38
Males
3
2.43
2.22
2
2.11
1.69
1.44
1
0
< 3 months
3-6
months
6-12
months
Source: Webb et al, Arch Gen Psychiatry, 2011
1-5 years 5-10 years > 10 years
Females
Deaths and police custody
Source: IPCC
National Diversion Programme
• Linked to care on prison release
• Linked to custody healthcare
• £30m funding recently agreed
• National rollout by 2017
“In some jails are confined
the mentally ill, although it is
probable that by medicines
and proper regiment, some of
them might be restored to
their senses and usefulness in
life.”
John Howard, 1780
www.medicine.manchester.ac.uk
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