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

BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7193.1235 (Published 08 May 1999) Cite this as: BMJ 1999;318:1235

Rapid Response:

Re: Local variation on national data

Dear Sir,

Dr Lowe’s letter gives me the chance to mention certain points about
our data collection systems which had to be omitted from our paper (1).

We do not receive information directly from coroners so we are not
affected by the local problems to which Dr Lowe refers. Through a
combination of local and national sources, we are confident that we
identify all suicides and open verdicts/ deaths from undetermined external
cause.

It is certainly reasonable to include some misadventures and
accidents in studies of suicide, though it is easier to do this in small
studies in which the details of each case can be assessed. Many studies
simply include all suicide and most or all open verdicts in the knowledge
that, while some cases will be omitted, there will be few false positives.
In effect, this is what the Office for National Statistics does when it
publishes national suicide rates, so our definition of suicide is well
established. Dr Lowe’s study appears to have excluded half the open
verdicts in the district after looking at the case details – this is a
high figure.

It is also true that identifying service contacts can be problematic,
particularly in areas where the population is mobile. For this reason, we
send information on suicides and probable suicides in a district to all
hospitals within that district and to some in other districts according to
known patterns of patient flow. The consultant psychiatrists who complete
our forms also sometimes tell us of contacts with other services.
However, the discrepancy in the figures quoted by Dr Lowe, i.e. the larger
proportion of suicides known to have been in contact with services by her
method of ascertainment in comparison to the Inquiry method, does not
arise from problems in identifying service contact. The difference,
although it sounds large at 20% of suicides, amounts to only 5 cases, and
all are from the cases who received inquest verdicts of misadventure or
accident. In other words, the difference arises entirely from the
definition of suicide.

I certainly agree that local studies of suicide can address local
problems which national studies do not detect, so that the two approaches
are complementary. Whether the higher proportion of violent suicides in
Dr Lowe’s district will persist once a larger number of cases has been
collected cannot yet be said, but this an example of a possible
characteristic of suicide locally which may warrant further study.

Yours sincerely,

Professor Louis Appleby
Director

1. Appleby L, Shaw J, Amos T, McDonnell R, Harris C, McCann K, et al.
Suicide within 12 months of contact with mental health services: national
clinical survey. BMJ 1999;318:1235-9

Shaw J, Appleby L, Amos T, McDonnell R, Harris C, McCann K et al. Mental
disorder and clinical care in people convicted of homicide: national
clinical survey. BMJ 1999;318:1240-4

Competing interests: No competing interests

02 June 1999
Louis Appleby
Director
Department of Psychiatry; University of Manchester