BMJ 1999;318:1235-1239 ( 8 May )

Papers

Suicide within 12 months of contact with mental health services: national clinical survey

Editorial by Geddes

Louis Appleby, director,  Jenny Shaw, assistant director,  Tim Amos, clinical research fellow,  Ros McDonnell, project manager,  Catherine Harris, research worker,  Kerry McCann, research worker,  Katy Kiernan, research assistant,  Sue Davies, research associate,  Harriet Bickley, research worker,  Rebecca Parsons, research worker. 

National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, School of Psychiatry and Behavioural Sciences, University of Manchester, Withington Hospital, Manchester M20 8LR

Correspondence to: Professor Appleby Louis.Appleby{at}man.ac.uk

Objective: To describe the clinical circumstances in which psychiatric patients commit suicide.
Design: National clinical survey.
Setting: England and Wales.
Subjects: A two year sample of people who had committed suicide, in particular those who had been in contact with mental health services in the 12 months before death.
Main outcome measures: Proportion of suicides in people who had had recent contact with mental health services; proportion of suicides in inpatients; proportion of people committing suicide and timing of suicide within three months of hospital discharge; proportion receiving high priority under the care programme approach; proportion who were recently non-compliant and not attending.
Results: 10 040 suicides were notified to the study between April 1996 and March 1998, of whom 2370 (24%; 95% confidence interval 23% to 24%) had had contact with mental health services in the year before death. Data were obtained on 2177, a response rate of 92%. In general these subjects had broad social and clinical needs. Alcohol and drug misuse were common. 358 (16%; 15% to 18%) were psychiatric inpatients at the time of death, 21% (17% to 25%) of whom were under special observation. Difficulties in observing patients because of ward design and nursing shortages were both reported in around a quarter of inpatient suicides. 519 (24%; 22% to 26%) suicides occurred within three months of hospital discharge, the highest number occurring in the first week after discharge. 914 (43%; 40% to 44%) were in the highest priority category for community care. 488 (26% excluding people whose compliance was unknown; 24% to 28%) were non-compliant with drug treatment while 486 (28%; 26% to 30%) community patients had lost contact with services. Most people who committed suicide were thought to have been at no or low immediate risk at the final service contact. Mental health teams believed suicide could have been prevented in 423 (22%; 20% to 24%) cases.
Conclusions: Several suicide prevention measures in mental health services are implied by these findings, including measures to improve compliance and prevent loss of contact with services. Inpatient facilities should remove structural difficulties in observing patients and fixtures that can be used in hanging. Prevention of suicide after discharge may require earlier follow up in the community. Better suicide prevention in psychiatric patients is likely to need measures to improve the safety of mental health services as a whole, rather than specific measures for people known to be at high risk.


Key messages

  • Around a quarter of people who commit suicide have been in contact with mental health services in the year before death---over 1000 cases annually

  • Of these cases, 16% are psychiatric inpatients and 24% have been discharged from inpatient care in the previous three months

  • Problems of observation caused by ward design and nursing shortages are common in cases of inpatient suicide

  • Suicide in former inpatients occurs most commonly in the week after discharge

  • Non-compliance with treatment and loss of contact with services are common before suicide




© BMJ 1999
Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to StumbleUpon StumbleUpon   Add to Technorati Technorati    What's this?

Relevant Articles

Suicide within 12 months of contact with mental health services
Alison Lowe, Emma Heap, Stirling Moorey, George Tadros, Emad Salib, M D Beary, Louis Appleby, and Jenny Shaw
BMJ 1999 319: 1433. [Extract] [Full Text]

Mental health services should aim to improve safety
BMJ 1999 318: 0. [Full Text]

Suicide and homicide by people with mental illness
John Geddes
BMJ 1999 318: 1225-1226. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

  • Chang, C.-M., Liao, S.-C., Chiang, H.-C., Chen, Y.-Y., Tseng, K.-C., Chau, Y.-L., Chang, H.-J., Lee, M.-B. (2009). Gender differences in healthcare service utilisation 1 year before suicide: national record linkage study. Br. J. Psychiatry 195: 459-460 [Abstract] [Full text]  
  • Ghali, S. (2009). On-site testing for drugs of misuse in the acute psychiatric ward. Psychiatr. Bull. 33: 343-346 [Abstract] [Full text]  
  • Pagura, J., Fotti, S., Katz, L. Y., Sareen, J., the Swampy Cree Suicide Prevention Team, (2009). Help Seeking and Perceived Need for Mental Health Care Among Individuals in Canada With Suicidal Behaviors. Psychiatr. Serv. 60: 943-949 [Abstract] [Full text]  
  • Lee, H.-C., Lin, H.-C. (2009). Are Psychiatrist Characteristics Associated With Postdischarge Suicide of Schizophrenia Patients?. Schizophr Bull 35: 760-765 [Abstract] [Full text]  
  • Karvonen, K., Hakko, H., Koponen, H., Meyer-Rochow, V. B., Rasanen, P. (2009). Suicides Among Older Persons in Finland and Time Since Hospitalization Discharge. Psychiatr. Serv. 60: 390-393 [Abstract] [Full text]  
  • Huisman, A., Robben, P. B. M., Kerkhof, A. J. F. M. (2009). An Examination of the Dutch Health Care Inspectorate's Supervision System for Suicides of Mental Health Care Users. Psychiatr. Serv. 60: 80-85 [Abstract] [Full text]  
  • Agerbo, E. (2007). High Income, Employment, Postgraduate Education, and Marriage: A Suicidal Cocktail Among Psychiatric Patients. Arch Gen Psychiatry 64: 1377-1384 [Abstract] [Full text]  
  • Feldman, M. D., Franks, P., Duberstein, P. R., Vannoy, S., Epstein, R., Kravitz, R. L. (2007). Let's Not Talk About It: Suicide Inquiry in Primary Care. Ann Fam Med 5: 412-418 [Abstract] [Full text]  
  • Kooyman, I., Dean, K., Harvey, S., Walsh, E. (2007). Outcomes of public concern in schizophrenia. Br. J. Psychiatry 191: s29-s36 [Abstract] [Full text]  
  • Shuchman, M. (2007). Falling through the Cracks -- Virginia Tech and the Restructuring of College Mental Health Services. NEJM 357: 105-110 [Full text]  
  • Pirkola, S., Sohlman, B., Heila, H., Wahlbeck, K. (2007). Reductions in Postdischarge Suicide After Deinstitutionalization and Decentralization: A Nationwide Register Study in Finland. Psychiatr. Serv. 58: 221-226 [Abstract] [Full text]  
  • Killaspy, H. (2007). From the asylum to community care: learning from experience. Br Med Bull 0: ldl017v1-14 [Abstract] [Full text]  
  • Meehan, J., Flynn, S., Hunt, I. M., Robinson, J., Bickley, H., Parsons, R., Amos, T., Kapur, N., Appleby, L., Shaw, J. (2006). Perpetrators of Homicide With Schizophrenia: A National Clinical Survey in England and Wales. Psychiatr. Serv. 57: 1648-1651 [Abstract] [Full text]  
  • Meloni, D., Miccinesi, G., Bencini, A., Conte, M., Crocetti, E., Zappa, M., Ferrara, M. (2006). Mortality Among Discharged Psychiatric Patients in Florence, Italy. Psychiatr. Serv. 57: 1474-1481 [Abstract] [Full text]  
  • Bale, R., Catty, J., Watt, H., Greenwood, N., Burns, T. (2006). Measures of the Therapeutic Relationship in Severe Psychotic Illness: A Comparison of Two Scales. Int J Soc Psychiatry 52: 256-266 [Abstract]  
  • MEEHAN, J., KAPUR, N., HUNT, I. M., TURNBULL, P., ROBINSON, J., BICKLEY, H., PARSONS, R., FLYNN, S., BURNS, J., AMOS, T., SHAW, J., APPLEBY, L. (2006). Suicide in mental health in-patients and within 3 months of discharge: National clinical survey. Br. J. Psychiatry 188: 129-134 [Abstract] [Full text]  
  • Penn, D. L., Simpson, L., Edie, G., Leggett, S., Wood, L., Hawgood, J., Krysinska, K., Yellowlees, P., De Leo, D. (2005). Development of ACROSSnet: an online support system for rural and remote community suicide prevention workers in Queensland, Australia. Health Informatics Journal 11: 275-293 [Abstract]  
  • McKENZIE, N., LANDAU, S., KAPUR, N., MEEHAN, J., ROBINSON, J., BICKLEY, H., PARSONS, R., APPLEBY, L. (2005). Clustering of suicides among people with mental illness. Br. J. Psychiatry 187: 476-480 [Abstract] [Full text]  
  • Qin, P., Nordentoft, M. (2005). Suicide Risk in Relation to Psychiatric Hospitalization: Evidence Based on Longitudinal Registers. Arch Gen Psychiatry 62: 427-432 [Abstract] [Full text]  
  • CLAASSEN, C. A., LARKIN, G. L. (2005). Occult suicidality in an emergency department population. Br. J. Psychiatry 186: 352-353 [Abstract] [Full text]  
  • Desai, R. A., Dausey, D. J., Rosenheck, R. A. (2005). Mental Health Service Delivery and Suicide Risk: The Role of Individual Patient and Facility Factors. Am. J. Psychiatry 162: 311-318 [Abstract] [Full text]  
  • Crawford, M. J. (2004). Suicide following discharge from in-patient psychiatric care. Adv. Psychiatr. Treat. 10: 434-438 [Abstract] [Full text]  
  • Hemmingsson, T., Kriebel, D. (2003). Smoking at age 18-20 and suicide during 26 years of follow-up--how can the association be explained?. Int J Epidemiol 32: 1000-1004 [Abstract] [Full text]  
  • WEAVER, T., MADDEN, P., CHARLES, V., STIMSON, G., RENTON, A., TYRER, P., BARNES, T., BENCH, C., MIDDLETON, H., WRIGHT, N., PATERSON, S., SHANAHAN, W., SEIVEWRIGHT, N., FORD, C. (2003). Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. Br. J. Psychiatry 183: 304-313 [Abstract] [Full text]  
  • HUNT, I. M., ROBINSON, J., BICKLEY, H., MEEHAN, J., PARSONS, R., McCANN, K., FLYNN, S., BURNS, J., SHAW, J., KAPUR, N., APPLEBY, L. (2003). Suicides in ethnic minorities within 12 months of contact with mental health services: National clinical survey. Br. J. Psychiatry 183: 155-160 [Abstract] [Full text]  
  • GAIRIN, I., HOUSE, A., OWENS, D. (2003). Attendance at the accident and emergency department in the year before suicide: retrospective study. Br. J. Psychiatry 183: 28-33 [Abstract] [Full text]  
  • EAGLES, J. M., CARSON, D. P., BEGG, A., NAJI, S. A. (2003). Suicide prevention: a study of patients' views. Br. J. Psychiatry 182: 261-265 [Abstract] [Full text]  
  • Garlow, S. J., D'Orio, B., Purselle, D. C. (2002). The Relationship of Restrictions on State Hospitalization and Suicides Among Emergency Psychiatric Patients. Psychiatr. Serv. 53: 1297-1300 [Abstract] [Full text]  
  • Luoma, J. B., Martin, C. E., Pearson, J. L. (2002). Contact With Mental Health and Primary Care Providers Before Suicide: A Review of the Evidence. Am. J. Psychiatry 159: 909-916 [Abstract] [Full text]  
  • Vassilas, C., Morgan, H. G. (2001). Suicide prevention: service contacts and coordination between primary and secondary care. Br. J. Psychiatry 179 : 271-271 [Full text]  
  • EAGLES, J. M., KLEIN, S., GRAY, N. M., DEWAR, I. G., ALEXANDER, D. A. (2001). Role of psychiatrists in the prediction and prevention of suicide: a perspective from north-east Scotland. Br. J. Psychiatry 178: 494-496 [Full text]  
  • KING, E. A., BALDWIN, D. S., SINCLAIR, J. M. A., CAMPBELL, M. J. (2001). The Wessex Recent In-Patient Suicide Study, 2: Case--control study of 59 in-patient suicides. Br. J. Psychiatry 178: 537-542 [Abstract] [Full text]  
  • Dhossche, D. M., Ulusarac, A., Syed, W. (2001). A Retrospective Study of General Hospital Patients Who Commit Suicide Shortly After Being Discharged From the Hospital. Arch Intern Med 161: 991-994 [Abstract] [Full text]  
  • Pirkis, J., Burgess, P., Meadows, G., Dunt, D. (2001). Self-Reported Needs for Care Among Persons Who Have Suicidal Ideation or Who Have Attempted Suicide. Psychiatr. Serv. 52: 381-383 [Abstract] [Full text]  
  • Raymont, V. (2001). Suicide in schizophrenia -- how can research influence training and clinical practice?. Psychiatr. Bull. 25: 46-50 [Full text]  
  • SEABOURNE, A., SEABOURNE, G. (2001). Suicide or accident - self-killing in medieval England: Series of 198 cases from the Eyre records. Br. J. Psychiatry 178: 42-47 [Abstract] [Full text]  
  • Burgess, P., Pirkis, J., Morton, J., Croke, E. (2000). Lessons From a Comprehensive Clinical Audit of Users of Psychiatric Services Who Committed Suicide. Psychiatr. Serv. 51: 1555-1560 [Abstract] [Full text]  
  • HAWTON, K., HARRISS, L., APPLEBY, L., JUSZCZAK, E., SIMKIN, S., McDONNELL, R., AMOS, T., KIERNAN, K., PARROTT, H. (2000). Effect of death of Diana, Princess of Wales on suicide and deliberate self-harm. Br. J. Psychiatry 177: 463-466 [Abstract] [Full text]  
  • APPLEBY, L., SHAW, J., AMOS, T., THOMAS, S., FERRIER, N., LEWIS, G. (2000). Sudden unexplained death in psychiatric in-patients. Br. J. Psychiatry 176: 405-406 [Full text]  
  • Fakhoury, W. (2000). Suicide: a call-sheet audit -- Data from SANELINE. Psychiatr. Bull. 24: 98-101 [Abstract] [Full text]  
  • Cattell, H. (2000). Suicide in the elderly. Adv. Psychiatr. Treat. 6: 102-108 [Full text]  
  • Appleby, L. (2000). Safer services: conclusions from the report of the National Confidential Inquiry. Adv. Psychiatr. Treat. 6: 5-15 [Full text]  
  • Lowe, A., Heap, E., Moorey, S., Tadros, G., Salib, E., Beary, M D, Appleby, L., Shaw, J. (1999). Suicide within 12 months of contact with mental health services. BMJ 319: 1433b-1433 [Full text]  
  • Geddes, J. (1999). Suicide and homicide by people with mental illness. BMJ 318: 1225-1226 [Full text]  
  • Shaw, J., Appleby, L., Amos, T., McDonnell, R., Harris, C., McCann, K., Kiernan, K., Davies, S., Bickley, H., Parsons, R. (1999). Mental disorder and clinical care in people convicted of homicide: national clinical survey. BMJ 318: 1240-1244 [Abstract] [Full text]  

Rapid Responses:

Read all Rapid Responses

Randomized trial evidence that stopping smoking reduced suicide numbers
Bruce Leistikow
bmj.com, 9 May 1999 [Full text]
Re: Randomized trial evidence that stopping smoking reduced suicide numbers
John Macleod
bmj.com, 11 May 1999 [Full text]
Lithium's antisuicidal effects
M T Abou-Saleh
bmj.com, 12 May 1999 [Full text]
Are the suicide statistics of suburban and rural psychiatric services really worse?
M D Beary
bmj.com, 12 May 1999 [Full text]
Re: Re: Randomized trial evidence that stopping smoking reduced suicide numbers
Bruce N Leistikow
bmj.com, 14 May 1999 [Full text]
Easy to criticise!
N Hussain
bmj.com, 15 May 1999 [Full text]
Re: Re: Re: Randomized trial evidence that stopping smoking reduced suicide numbers
John Macleod
bmj.com, 17 May 1999 [Full text]
Difficulty of applying national trends to local areas
Alison Lowe
bmj.com, 21 May 1999 [Full text]
Local variation on national data
Alison Lowe
bmj.com, 20 May 1999 [Full text]
Re: Local variation on national data
Louis Appleby
bmj.com, 2 Jun 1999 [Full text]
liaison nursing
T John
bmj.com, 8 Jun 1999 [Full text]
Access jobs at BMJ Careers
Whats new online at Student BMJ