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clinmed/2003040007v1 (February 25, 2004)
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First round analysis of the confidential inquiry into homicides and suicides by mentally ill people in Leeds, UK.

by

 

SAID SHAHTAHMASEBI, PhD

Senior Lecturer,

School of Mathematics & Statistics

Faculty of Health and Sciences

CPIT, PO Box 540

Christchurch, New Zealand.

Tel: +64 (03) 940 8191

Fax +64 (03) 940 8622

Email: saids@cpit.ac.nz

 

 

An earlier version of this paper was presented at the Australian Society for Psychiatric Research (ASPR) Conference, Canberra, 5-6 December 2002, Australia.

April 2003

 

Acknowledgement

The author is grateful to the Leeds Community Mental Health Services NHS Trust for their permission to use the data which became available during the authors employment with the Trust, to Dr John Wattis (MBCHB; DPM; FRCPsych), Medical Director, for his helpful comments on the manuscript, and to Mr Paul Newton the Clinical Audit Manager for his assistance in accessing the data.

 

 

First round analysis of the confidential inquiry into homicides and suicides by mentally ill people in Leeds, UK.

Abstract

Aim: to explore characteristics of suicide cases with a psychiatric record.

Background: In 1992, in the UK, following consultations with the Royal College of Psychiatrists, the confidential inquiry into homicides and suicides by mentally ill people was set up by the Department of Health. The inquiry collects detailed information on contact with secondary mental health services by means of a questionnaire from clinical audit or information departments from these organisations.

Methodology: In Leeds, however, a wider range of available records including Coroner Reports, police, social, educational and all health records were consulted. This resulted in a series of health/life event histories of suicide cases that had been in contact with psychiatric services. This paper presents an exploratory analysis of a these data.

Results: The Leeds suicide cases formed only one-third of all suicide cases in Leeds the remainder two-third had not come into contact with psychiatric services; this proportion is consistent with the UK national figures. 46% of the sampleís first contact with the psychiatric services was through a first failed attempted suicide. Other results include the role of prescribed drugs in repeat suicide attempts, education levels and employment stability.

Conclusion: The link between mental illness and suicide is questionable. Life event history type data on all suicide cases is desperately required to study suicide as a social process.

Keywords: community records, health informatics, life events.

 

Introduction

Suicide has received a great deal of attention from various scientific disciplines. The literature suggests that there are multiple factors that contribute to the suicide rate,, thus it is too simple a picture to assume a causal relationship between mental illness and suicide. For example, in a cohort, there may be subjects with similar characteristics; one may attempt suicide while another may not. A full literature review is beyond the scope of this paper, however, literature has been reviewed recently elsewhere,,,,. The literature, while accepting suicide as a process, often restricts its dynamics to the events immediately preceding death. The major problem is that the key informants are no longer available to provide insight into the events. On the other hand, prospective designs require large samples over long periods of time, which are often ethically complex and financially prohibitive. For this reason, studies of suicide have mainly been retrospective using psychiatric records and notes or studying of a sub-population e.g. those with failed attempted suicide, or those with a history of self-harm. Such studies are limiting as they exclude the full dynamics life processes and may lead to a spurious relationship between psychiatric history and suicide.

Current evidence suggests an ambiguous relationship between mental illness and suicide,. For example Wattis suggests an underestimation of the prevalence of depression in the population, and, Blair-West and colleagues argue that the mortality rate of 15 per 100,000 due to suicide amongst subjects with major depressive disorder is well overestimated and is more likely to be at 3.5%. They suggest that the source of data and population on which the calculations are based contribute to this overestimation.

Background

Few studies have investigated suicide using community medical records (GPs) in addition to psychiatric records,. A recent study reported suicide trends based on data gathered from hospital/casualty department, police force spanning over six years. The authors report a number of demographic and social variables as well as mental illness being significantly related to suicide. They also report some data limitation related to registration and coding of such official data.

In 1992, following consultations with the Royal College of Psychiatrists, the confidential inquiry into homicides and suicides by mentally ill people was set up by the Department of Health. The inquiry collects detailed information on contact with secondary mental health services by means of a questionnaire from clinical audit or information departments from these organisations. In Leeds, however, a wider range of available records including Coroner Reports and all health records were consulted. This resulted in a series of health/life event histories of suicide cases that had been in contact with psychiatric services. In most cases a health/life event history can be constructed. Analysis of such data requires a well thought out methodology that incorporates the complexities of multiple time series data, which are both quantitative and qualitative. This paper reports results from the first round of exploratory analysis of these data providing a wider perspective for investigation and analysis of suicide.

Methodology

A comprehensively designed proforma was used for the purpose of data extraction from the public and medical records. The data gathered included both quantitative and qualitative data. Demographic and socio-economic information were generally of quantitative nature whilst narration of ill-health, social and educational histories were qualitative in nature. These are the subject of a further textual and data mining exercise and will be reported on completion.

However, to obtain an initial view of the distribution in the sample of childhood, adolescence and education the analysis was restricted to the presence or absence a life/health event and its type. For example, turbulent childhood, violence within the family, problems at school and problems with educational development, are used as proxy to indicate existence of problems during the growing up years. That is to say, the post coding is not based on any prior theoretical background or assumptions and No attempt is made to investigate complex inter-relationships between various demographic and socio-economic backgrounds and suicide. . The main reason for these proxy variables is that all the cases are suicide cases, they all had at least one contact with psychiatric services and the sample excludes those cases without contact with the services.

In this paper we report results from the preliminary analysis of the quantitative data. No attempt is made to investigate complex inter-relationships between various demographic and socio-economic backgrounds and suicide. This is because the sampled population are all suicide cases. A limitation of this study is that we have no knowledge about cases of suicide that had no contact with psychiatric services.

Sample characteristics

Demographic background of the sample

During the period 1993-96 forty-eight cases of suicide that had received psychiatric care had been identified. These are shown in Table 1 by type of coronersí verdict and gender. The age/sex distribution in the sample is similar to other studies reporting suicides in the North of England,. There are more men in the sample than women, 30 men (mean age 39, 95% CI 35-43) and 18 women (mean age 49, 95% CI 43-56). The age difference between the sexes appears to be statistically significant (t = 2.84, P < 0.01).

Social background of the sample

Initial assessment of the data suggests that the majority of the cases (65%) may have had a reasonable childhood, as there were no records of any major events during those years, around 17% had a record of unstable childhood history (e.g. trauma, bullying at school, divorcing parents), 8% had records of other major childhood problems (e.g. exposure to violence) and the childhood/adolescence of the remaining 10% of the sample were unknown.

Ten per cent of those with no recorded events during childhood developed an unstable adolescence and only one case in this group had a more turbulent adolescence with a police/prison record. Of those with an unstable childhood, 50% continued to have an unstable adolescence; 25% developed problems with the police or had a prison record; one case was referred to the child psychiatric unit; only one case appeared with no record of any major life event during adolescence.

The remaining 8% included two cases of childhood exposure to violence within the family of which one had police records and a prison record and the other appeared without any major life events during adolescence; one case received special schooling in childhood and developed an unstable adolescence; and, finally, one case with a childhood history under the care of social services had an apparent uneventful adolescence.

Education and employment history

The majority of the sample had a poor educational history; around 71% of the sample appeared to have left school without any qualifications. This is quite a large proportion of the sample and is likely to be unrepresentative of the general population of Leeds. For example, a survey of Leeds employees found that 27% of their workforce had no qualification. The overall unemployment rate in Leeds for the years 1994, 1995 was reported to be 8.5% and 7.6% respectively but around 21% of the sample were recorded as long term unemployed, whilst 19% had been through a variety of jobs (not being able to sustain a job for long) and only around 25% had managed to sustain at least one job for a period of time.

First contact with Psychiatric Services

Table 2 reveals that whilst 33% were self-referred to the psychiatric services including a small proportion who had been referred by their GP, around 46% of the sampleís first contact with psychiatric services was due to their first failed attempted suicide. In total, our sample generates a raw suicide mortality ratio of 2 per 100,000 population for 1993, 1994, and 1.3 and 1.6 per 100,000 population for 1995 and 1996 respectively. Regional mortality data suggests a much higher mortality due to suicide with or without contact with mental health services. For example the 1993 standardised mortality ratio (SMR) for suicide and undetermined injury for the Leeds Health Authority geographical area in the UK was around 16 per 100,000 population.

Morbidity background and diagnosis

Our data suggest that psychosis was rare. However, the records indicated that around 65% had a medical history such as chronic physical illness. 42% of the sample had a medical history within the family. Similarly, 40% had a family history of psychiatric illness e.g. one of the parents. From these records 69% had a recorded diagnosis 13% of which had a second and 4% had a third diagnosis. Table 3 shows the distribution of diagnosis for the sample; 15 (31%) of the sample had no recorded diagnosis, and, 17% had a recorded depressive illness. The "other" category did not have a recorded diagnosis, but the word depression or depressive illness had been mentioned in the textual comments. It can be seen that it would be easy, if care is not exercised, to make a link between suicide and depression. Caution must be applied when interpreting such information because the sample is limited to only those with a psychiatric record; we donít have enough information about those without a record; we know that in the general population there are people with similar characteristics who do not commit suicide.

Furthermore, it should be noted that for about half the sample a psychiatric assessment and diagnosis had been carried out following the suicide attempt. In most studies of suicide, self-harm and attempted suicide is assumed a precursor to a psychiatric diagnosis often a depressive illness. The implication may well be a feed back effect in which attempted suicide cases may have a higher rate of being diagnosed with a depressive illness. Some studies suggest that those who attempt suicide with intent to die are more likely to be depressed and feel hopeless. Almost always we have no knowledge of the level of depression prior to suicide and unable to distinguish past behaviour effect from the possible cumulative effects of failure to complete the process of suicide.

Self-harm History

Out of the 73% with a history of attempted suicide, 37% had attempted once before, 26% had attempted twice and 23%, nine or more times before. Forty two per cent of the sample died within six months of previous unsuccessful attempts. This result is generally in agreement with the literature and comparable with the results from other studies e.g see McKenzie and Wurr. Since we know very little about the larger proportion of the cases of completed suicide first time, caution must be exercised in interpreting and attaching too much weight to this variable as a precursor of suicide.

Prescribed Drugs

A further point of concern to the care service is that prescribed drugs were involved in combination or on their own in 61% of the cases who died as a result of overdose. This is rather disconcerting as an analysis of method of previous attempts suggested that prescribed drugs were also involved in 57% of the cases. There have been a number of practice changes and legislation regarding drugs and prescriptions, e.g the manufacturing of non-toxic drugs, limiting public access to a large number of household and commonly available pain killers. Despite such changes, our data suggests that there is a tendency to switch methods in subsequent suicide attempts until successful. An increasing suicide trend together with evidence of switching between methods suggest that whilst mortality due to drug overdose may have been contained, there has been no impact on the overall suicide attempt and suicide mortality rate. Similarly, recent data from New Zealand suggest that methods such as hanging (40%) and poisoning by other gases (28%) are becoming more common . Prescription and drug management is clearly an important issue and needs to be considered strategically in conjunction with other policies.

Alcohol Abuse

Around 15% of our sample had a history of alcohol abuse and had been referred to the addiction unit either through their GPs or through Psychiatric Services. Only in one case alcohol was determined as the main method of suicide.

Discussion and conclusions

The preliminary study of case histories reveal a number of interesting points:

Although all the cases in our sample had come into contact with psychiatric services, some completed suicide whilst in care and, some completed suicide within days (less than 5 days) of discharge following weeks of treatment. Others completed suicide within months, and, only in one case suicide was completed over ten years after the previous attempt. The question for the service is whether medical treatment is merely a delaying mechanism or a potential remedy. Other issues to be considered for service development are what factors govern the life processes that reduces resilience to suicide; health and social care of those who do not come into contact with community services; and the quality of life following treatments and in between attempts. To address these issues access to quality information is essential.

Information is the most important currency in health care development and provision. More attention must be paid to the development and support of studies that lead to an improved health care information system e.g the design and utilisation of a unified database. One of the ways that a unified database may assist would be an expected improved communication between health care professionals. Improvements in communication could perhaps be achieved through an integrated electronic patientsí record. Such a unified information system could facilitate the development and utilisation of available information on patientsí case histories and enable risks to be "flagged".

References

 

1. Rogers A, Pilgrim D. Mental health policy in Britain. Basingstoke: MacMillan Press; 1996.

2. Bughan R. Suicide: A summary of different approaches: Banstead: COHSE; 1993.

3. Clark VA, Frankish CJ, Green LW. Understanding Suicide among indigenous adolescents: a review using the PRECEDE model. Inj. Prev. 1997;3(2):126-34.

4. Royal College of Psychiatrists. Report of the Confidential Inquiry into Homicides and Suicides by Mentally Ill People: Steering Committee of the Confidential Inquiry into Homicides and Suicides by Mentally Ill People, Unit Office, PO Box 1515, London SW1X 8PL; 1996.

5. Charlton B, Kelly S, Dunnell K, et al. Suicide deaths in England and Wales: Trends in factors associated with suicide deaths. Population Trends 1993;71:34-42.

6. Appleby L. Suicide in psychiatric patients: risk and prevention. British Journal of psychiatry 1992;161:749-758.

7. Morgan HG, Priest P. Suicides and other unexpected deaths among psychiatric in-patients. British Journal of Psychiatry 1991;158:368-374.

8. Wattis JP. Difficulties in diagnosis of depression in the elderly. Spectrum International 1995;XXXV(6-7).

9. Blair-West GW, Mellsop GW, Eyeson-Annan ML. Down-rating lifetime suicide risk in major depression. Acta Psychiatr Scand 1997;95(3):259-263.

10. Redpath L, Stacey A, Pugh E, Holmes E. Use of the critical incident technique in primary care in the audit of deaths by suicide. Quality in Health Care 1997;6:25-28.

11. Milne S, Matthews K, Ashcroft GW. Suicides in Scotland 1988-1989, Psychiatric and Physical Morbidity According to Primary Care Case Notes. British Journal of Psychiatry 1994;165(4):541-4.

12. Torre E, Chieppa N, Jona A, Ponzetti D, Usai C, Zeppegno P. Suicide and attempted suicide in the province of Turin from 1988 to 1994: Epidemiological Analysis. Eur. J. Psychiat. 1999;13(2):77-86.

13. Blain PA, Donaldson LJ. The reporting of in-patient suicides: identifying the problem. Public Health 1995;109:293-301.

14. Rajan A, Jaspers A. Achieving the National Targets; Obstacles and Solutions. CREATE 1995;Tunbridge Wells:23.

15. Leeds Economic and Labour Market Assessment 1995/96. Leeds, UK: Leeds Training and Enterprise Council; 1995 1995.

16. Bensely D, Shahtahmasebi S, Merrick D, Fryers P, Fryers PT. A census based view of the population and its health - statistical review. Harrogate: Yorkshire Regional Health Authority; 1994.

17. Groholt B, Ekeberg O, Haldosen T. Adolescents hospitalised with deliberate self-harm: the significance of an intention to die. Eur Child Adolesc Psychiatry 2000;9(4):244-54.

18. McKenzie W, Wurr C. Early suicide following discharge from a psychiatric hospital. Suicide and Life Threatening Behaviour 2001;31(3):358-63.

19. NZIHS. Suicide trends in New Zealand 1978-98. http://www.nzhis.govt.nz/publications/suicide.html 2001.

20. Khan A, Warner HA, Brown WA. Symptom Reduction and Suicide Risk in Patients Treated With Placebo in Antidepressant Clinical Trials: An Analysis of the Food and Drug Administration Database. Arch Gen Psychiatry 2000;57:311-317.

 

 

 

Table 1 Identified self harm fatality while under Psychiatric Care

Male Female Total

Suicide

13

5

18

Open

16

10

26

Misadventure

1

2

3

Not Clear

 

1

1

Total

30

18

48

Table 2 Method of coming into contact with Psychiatric Services

 

Frequency in the Sample

Percentage %

Attempted Suicide

22

46

Addiction (Alcohol)

6

13

Other (e.g. self referral)

16

33

Not known

4

8

Total

48

100

 

Table 3. The Sample Distribution of Psychiatric Diagnosis

First Diagnosis

Frequency

Percentage

Depressive illness

8

16.7

Schizophrenia

6

12.5

Personality disorder

3

6.3

Alcoholism

4

8.3

Paranoid illness

2

4.2

Anxiety state

1

2.1

Other

8

16.7

No-diagnosis

1

2.1

 Non-recorded

15 

 31.3

Total

48

100

 

 





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