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. Louis Appleby Professor of Psychiatry

Suicide rates, England Ages Age standardised death rate per 100,000 population Source: ONS 3-year average

Suicide rates by age and gender, England 2012 Source: ONS

Suicide methods, England 2012 Source: ONS

Deaths mentioning helium poisoning, England 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 Persons, All Ages Three-year average rate, plotted against final year of average Males Source: ONS 2010

Suicide rates in the general population, UK country UK COMPARISONS ( )_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.

Suicide rates in the general population, by age-group and UK country ( ) UK COMPARISONS ( )_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.

UK ( ) England ( ) Wales ( ) Scotland ( ) N. Ireland ( ) NNNNN General population 100,32978,1705,47513,2353,449 In contact with services 26,216 (26%) 20,300 (26%) 1,260 (23%) 3,705 (28%) 951 (28%) National Confidential Inquiry: suicides

Patient suicides: cause of death by gender ENGLAND_SUICIDE ( ) © 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.

Patient suicides: primary diagnosis by gender ENGLAND_SUICIDE ( ) © 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.

Living circumstances: patient suicides ENGLAND_SUICIDE ( ) © 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 ENGLAND_SUICIDE ( ) © 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 – 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 )

Number of suicides under CRHT and mental health in-patients (England, )

Number of patient suicides per week following discharge ( ) ENGLAND_SUICIDE ( ) © 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.

OR95% CI Age > Male gender Self-harm Secondary diagnosis Recent life events Admission <1 week duration Under CPA Source: Bickley et al, Psychiatric Services, 2013 Independent risk factors for suicide within 2 weeks of discharge

Timing of last contact: patient suicides ENGLAND_SUICIDE ( ) © 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.

Mental health teams’ estimation of suicide risk at last contact: patient suicides ENGLAND_SUICIDE ( ) © 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.

Mental health teams contact with relatives after suicide: patient suicides ENGLAND_SUICIDE ( ) © 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.

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, Steps to a Safer Service

Number of recommendations implemented

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

Prison suicides: diagnosis Any diagnosis46% Of which: Depression35% Personality disorder 10% Drug misuse 26% Alcohol misuse 24%

Prison suicides: time since reception

Prison suicides: method (93%) died by hanging 311 (61%) used bed-clothes as ligatures 251 (49%) used window bars

Independent predictorAdjusted Odds RatioP-value (95% CI) History of self-harm5.03 ( )<0.001 Occupying a single cell3.70 ( )<0.001 Remand status3.28 ( ) Previous service contact2.38 ( ) Case control study of prison suicide

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 Time from release (28 day periods) Source: Pratt et al, Lancet 2006 No. suicides

Criminal justice history and suicide Source: Webb et al, Arch Gen Psychiatry, 2011 Odds ratio

Offence type and suicide Source: Webb et al, Arch Gen Psychiatry, 2011 Odds ratio

Time since CJS contact and suicide Source: Webb et al, Arch Gen Psychiatry, 2011 Odds ratio

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

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