nci annual report 2013 © national confidential inquiry into suicide and homicide by people with...

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 ApplebyProfessor of Psychiatry

Suicide rates, England 1994-2012

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 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

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

Suicide rates in the general population, UK country

10.6 10.5 10.0 9.4 9.310.1

9.4 9.38.8

10.6 10.6

14.7

18.5

14.7

16.717.0

15.3 14.915.9

12.4

13.9

11.1

19.5 19.8

17.618.7

17.2 16.818.2 18.2

16.5

16.8

18.9

12.012.0 11.511.110.5

11.311.111.1

12.8

12.8

14.4

0

5

10

15

20

25

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

Su

icid

e ra

te p

er 1

00,0

00 p

op

ula

tio

n

England Northern Ireland Scotland Wales

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.

Suicide rates in the general population, by

age-group and UK country (2001-2011)

0

5

10

15

20

25

30

10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+

Age-groups

Su

icid

e r

ate

per

100,0

00 p

op

ula

tio

n

England Northern Ireland Scotland Wales

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.

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: cause of death by gender

45%

22%

4%

16%

5%

10%

30%

37%

1%

15%8% 9%

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Hanging/strangulation Self-poisoning Carbon monoxidepoisoning

Jumping/multipleinjuries

Drowning Other

Cause of death

Nu

mb

er o

f su

icid

es

Male Female

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.

Patient suicides: primary diagnosis by gender

42%

20%

7%10%

5%13%

55%

12%

6%2%

0

500

1000

1500

2000

2500

3000

3500

4000

Schizophrenia Affective disorder Personalitydisorder

Alcoholdependence

Drugdependence

Nu

mb

er o

f su

icid

es

Male Female


Living circumstances: patient suicides

Prison/YOI70 (1%)

With children only555 (4%)

Other shared (e.g. friends)

651 (5%)

With spouse/partner (w ith or w ithout

children)3793 (30%)

With parent(s)1435 (11%)

Alone 5768 (46%)

Other specified310 (2%)


In-patient suicides – cause of death


8%8%

28%

2%

6%

49%

11%10%

26%

1%

15%

36%

0

50

100

150

200

250

300

350

400

450

500

Hanging/strangulation Self-poisoning Carbon monoxidepoisoning

Jumping/multipleinjuries

Drow ning Other

Cause of death

Nu

mb

er o

f su

icid

es

Male Female

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)

Number of suicides under CRHT and mental health in-patients (England, 2003-2011)

Number of patient suicides per week following discharge (2001-2011)


114118125139144136

165

194

217

253

284

375

117

0

50

100

150

200

250

300

350

400

1 2 3 4 5 6 7 8 9 10 11 12 13

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

Nu

mb

er o

f su

icid

es

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

Independent risk factors for suicide within 2 weeks of discharge

Timing of last contact: patient suicides

18%

31%

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 su

icid

es


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

9%

31%

47%

12%

2%

12%

57%

29%

0

1000

2000

3000

4000

5000

6000

7000

8000

No risk Low Moderate High

Suicide risk

Nu

mb

er o

f su

icid

es

Long-term risk Immediate risk


Mental health teams contact with relatives after suicide: patient suicides

Other92 (1%)

None3754 (32%)

Letter872 (8%)

Discussion (face to face or

telephone)6857 (59%)


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 managementSafety First, 200112 Steps to a Safer Service

0

10

20

30

40

50

60

70

80

1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

Nu

mb

er o

f T

ru

sts

0 (none) 1 2 3 4 5 6 7 8 9 (all)

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 diagnosis 46%

Of which:

Depression 35%Personality disorder 10%

Drug misuse 26%

Alcohol misuse 24%

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

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

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

0

10

20

30

40

50

60

70

80

90

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

No. suicides

2.27

4.81

2.05

5.33

3.843.31

8.88

3.05

11.34

5.5

0123456789

101112

Any verdict Custodial sentence

Fined Charges withdrawn

Acquitted

Males

Females

Criminal justice history and suicide

Source: Webb et al, Arch Gen Psychiatry, 2011

Odds ratio

3.75

4.62

3.75

2.13

2.94

0

8.4

4.48

2.8

4.41

0

1

2

3

4

5

6

7

8

9

Sexual Violent Property Traffic All other offences

Males

Females

Offence type and suicide


Odds ratio

4.95

3.9

3.38

2.22

1.691.44

6.39

5.725.43

3.74

2.432.11

0

1

2

3

4

5

6

7

< 3 months 3-6 months

6-12 months

1-5 years 5-10 years > 10 years

Males

Females

Time since CJS contact and suicide


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

www.medicine.manchester.ac.uk

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nci annual report 2013 © national confidential inquiry into suicide and homicide by people with...

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