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Background: Homicide-suicides are rare events in which an individual commits a homicide and then takes his or her own life. Despite extensive media coverage and a recent increase in research in this field, our understanding of these events is limited as most studies are descriptive. There is little reliable evidence regarding mental illness in individuals who commit homicide-suicide. Aims: The central aim of this study was to examine the role of mental illness in cases of homicide-suicide. The objectives were to: (1) determine the prevalence of mental illness; (2) describe the characteristics of perpetrators and victims, and the circumstances of the offence; (3) examine the psychopathology of perpetrators prior to the offence. Method: The research design was a mixed methods study of homicide-suicide. Quantitative and qualitative techniques were used to examine a national consecutive case series, in England and Wales, between 1st January 2006 and 31st December 2008. The sample contained 60 cases. Descriptive statistical analysis and a thematic framework analysis were undertaken on documents obtained from coroners, the police, GP medical records, records of mental health services contact and newspaper articles. The social, behavioural, offence and clinical characteristics of these incidents were reported. Results: Most of these offences were committed by men (53, 88%). The average age of perpetrators was 44 years (range 18-85). The overwhelming majority of these incidents involved close family members, mainly current or former intimate partners and/or the children of the perpetrator. Over half of the perpetrators had previously been diagnosed with mental health problems by a GP, most commonly depression. The incident was, in most cases, preceded by an actual separation from an intimate partner, or the perpetrator perceived separation to be imminent. The emotional responses to the loss of the relationship included: anger; frustration; humiliation; jealousy; desire for revenge; hopelessness, guilt and remorse. Poor coping strategies were observed, with many having a history of previous self-harm or suicide attempts, and difficulty controlling their aggression. Despite the high proportion of lifetime mental illness, few had been in recent contact with their GP for psychological problems prior to the incident. In the majority of cases, incidents involving mentally ill perpetrators were reported responsibly in newspapers. However, there were instances in which journalists sensationalised the incidents and provided stereotypical portrayals of the perpetrator. Conclusion: The findings from this study add valuable empirical qualitative data to the literature. These incidents occur in the context of existing and challenging common social issues, such as intimate partner violence, child custody disputes, an ageing population, and mental disorder. The evidence from this study shows that these perpetrators had an extreme reaction to an interpersonal crisis resulting in severe emotional distress. Perpetrators from vulnerable groups had complex needs and exhibited previous poor coping strategies that may put them at increased risk. However, prevention is difficult as these are rare events and though under distress, these individuals were less likely to seek help from services. More research is required to identify risk factors in targeted sub-groups of homicide-suicide, such as intimate partner, filicide-suicide and elderly homicide-suicide, in the context of social, economic and clinical problems.

Introduction: The global burden of diabetes can be minimised by interventions focusing on the control of glucose levels. Effective self-management and quality of care have improved diabetes outcomes such as glycaemic levels. However, few studies directly evaluate the relative importance of individual aspects of self-management and quality of care on glycaemic control. Therefore, I evaluated the individual contribution and relative importance of specific aspects of self-management and quality of care on the glycaemic control of Mexican patients with type 2 diabetes. Methods: A longitudinal cohort study was conducted. Consecutive patients were recruited from the waiting rooms in five primary care practices in the city of Aguascalientes, Mexico (from December 2009 to April 2010). These practices are part of the largest social security institution in Mexico (the Mexican Institute for Social Security). Predictors of glycaemic control were measured from medical records and interviews with patients at baseline. Self-management was measured using four questionnaires: the Diabetes Knowledge Questionnaire (DKQ-24), the Medical Prescription Knowledge Questionnaire (MPKQ), the Summary of Diabetes Self-Care Activities (SDSCA), and the Diabetes Self Efficacy Scale. Quality of care was measured using three questionnaires and by extracting data from medical records to evaluate an index of continuity of care (MMCI) and treatment intensification. The questionnaires used were the continuity of care scale from the General Practice Assessment Questionnaire (GPAQ), the Patient–Doctor Communication Scale (PDCS), and the Patient Satisfaction with Diabetes Care scale (PSDC). Glycaemic control (HbA1c levels) was measured at two time points: baseline and six month follow-up. The main analysis was a multivariate regression model with HbA1c at six-month follow-up as the dependent variable and with self-management and quality of care as predictors and demographic and clinical factors as covariates. A secondary analysis considered the interaction between self-management and quality of care in the prediction of HbA1c at six-month follow-up using a multivariate regression model including HbA1c at baseline in the model. Results: The multivariate linear regression model, that included all variables, was significant and explained 36 % of the variance (P <0.01). Patients had lower HbA1c at follow-up if they had lower levels of HbA1c at baseline, received care at one particular practice in the city, had diabetes of shorter duration, and were prescribed monotherapy. When HbA1c at baseline was removed from the model it explained 14% of the variance (P <0.01). Practice and medical prescription remained significant. In addition, lower levels of HbA1c at follow-up were related to the patient undergoing appropriate treatment intensification by their general practitioner. In the secondary analysis, the interaction showed that if treatment was not intensified, good self-managers had lower HbA1c (P <0.01) but if treatment was intensified, the level of self-management had no effect. Conclusions: Treatment intensification was the main predictor of lower HbA1c levels at follow-up. Although none of the self-management predictors was significantly related to HbA1c, an exploratory analysis of self-management/quality of care interactions showed that patients who did not receive treatment intensification but performed more self-management behaviours had lower HbA1c levels at follow-up.