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Background: We investigated disparities in the clinical management of self-harm following hospital presentation with self-harm according to level of socio-economic deprivation (SED) in England. Methods: 108 092 presentations to hospitals (by 57 306 individuals) after self-harm in the Multicenter Study of Self-harm spanning 17 years. Area-level SED was based on the English Index of Multiple Deprivation. Information about indicators of clinical care was obtained from each hospital's self-harm monitoring systems. We assessed the associations of SED with indicators of care using mixed effect models. Results: Controlling for confounders, psychosocial assessment and admission to a general medical ward were less likely for presentations by patients living in more deprived areas relative to presentations by patients from the least deprived areas. Referral for outpatient mental health care was less likely for presentations by patients from the two most deprived localities (most deprived: adjusted odd ratio [aOR] 0.77, 95% CI 0.71–0.83, p < 0.0001; 2nd most deprived: aOR 0.80, 95% CI 0.74–0.87, p < 0.0001). Referral to substance use services and 'other' services increased with increased SED. Overall, referral for aftercare was less likely following presentations by patients living in the two most deprived areas (most deprived: aOR 0.85, 95% CI 0.78–0.92, p < 0.0001; 2nd most deprived: aOR 0.86, 95% CI 0.79–0.94, p = 0.001). Conclusions: SED is associated with differential care for patients who self-harm in England. Inequalities in care may exacerbate the risk of adverse outcomes in this disadvantaged population. Further work is needed to understand the reasons for these differences and ways of providing more equitable care. [ABSTRACT FROM AUTHOR]

Background: Few studies have examined online experience by young people who die by suicide. Methods: A 3-year UK-wide consecutive case series of all young people aged 10–19 who died by suicide, based on national mortality data. We extracted information on the antecedents of suicide of 544 of these 595 deaths (91%) from official investigations, mainly inquests. Results: Suicide-related online experience was reported in 24% (n = 128/544) of suicide deaths in young people between 2014 and 2016, equivalent to 43 deaths per year, and was more common in girls than boys (OR 1.87, 95% CI 1.23–2.85, p = 0.003) and those identifying as LGBT (OR 2.35, 95% CI 1.10–5.05, p = 0.028). Searching for information about method was most common (n = 68, 13%), followed by posting suicidal ideas online (n = 57, 10%). Self-harm, bereavement (especially by suicide), social isolation, and mental and physical ill-health were more likely in those known to have suicide-related online experience compared to those who did not. 29 (5%) were bullied online, more often girls (OR 2.84, 1.34–6.04, p = 0.007). Online bullying often accompanied face-to-face bullying (n = 16/29, 67%). Conclusions: Suicide-related online experience is a common, but likely underestimated, antecedent to suicide in young people. Although its causal role is unclear, it may influence suicidality in this population. Mental health professionals should be aware that suicide-related online experience – not limited to social media – is a potential risk for young patients, and may be linked to experiences offline. For public health, wider action is required on internet regulation and support for children and their families. [ABSTRACT FROM AUTHOR]

Background. Persons discharged from inpatient psychiatric services are at greatly elevated risk of harming themselves or inflicting violence on others, but no studies have reported genderspecific absolute risks for these two outcomes across the spectrum of psychiatric diagnoses. We aimed to estimate absolute risks for self-harm and interpersonal violence post-discharge according to gender and diagnostic category. Methods. Danish national registry data were utilized to investigate 62,922 discharged inpatients, born 1967–2000. An age and gender matched cohort study was conducted to examine risks for self-harm and interpersonal violence at 1 year and at 10 years post-discharge. Absolute risks were estimated as cumulative incidence percentage values. Results. Patients diagnosed with substance misuse disorders were at especially elevated risk, with the absolute risks for either self-harm or interpersonal violence being 15.6% (95% CI 14.9, 16.3%) of males and 16.8% (15.6, 18.1%) of females at 1 year post-discharge, rising to 45.7% (44.5, 46.8%) and 39.0% (37.1, 40.8%), respectively, within 10 years. Diagnoses of personality disorders and early onset behavioral and emotional disorders were also associated with particularly high absolute risks, whilst risks linked with schizophrenia and related disorders, mood disorders, and anxiety/somatoform disorders, were considerably lower. Conclusions. Patients diagnosed with substance misuse disorders, personality disorders and early onset behavioral and emotional disorders are at especially high risk for internally and externally directed violence. It is crucial, however, that these already marginalized individuals are not further stigmatized. Enhanced care at discharge and during the challenging transition back to life in the community is needed. [ABSTRACT FROM AUTHOR]

Aims: People diagnosed with a severe mental illness (SMI) are at elevated risk of dying prematurely compared to the general population. We aimed to understand the additional risk among people with SMI after discharge from inpatient psychiatric care, when many patients experience an acute phase of their illness. Methods: In the Clinical Practice Research Datalink (CPRD) GOLD and Aurum datasets, adults aged 18 years and older who were discharged from psychiatric inpatient care in England between 2001 and 2018 with primary diagnoses of SMI (schizophrenia, bipolar disorder, other psychoses) were matched by age and gender with up to five individuals with SMI and without recent hospital stays. Using survival analysis approaches, cumulative incidence and adjusted hazard ratios were estimated for all-cause mortality, external and natural causes of death, and suicide. All analyses were stratified by younger, middle and older ages and also by gender. Results: In the year after their discharge, the risk of dying by all causes examined was higher than among individuals with SMI who had not received inpatient psychiatric care recently. Suicide risk was 11.6 times (95% CI 6.4–20.9) higher in the first 3 months and remained greater at 2–5 years after discharge (HR 2.3, 1.7–3.2). This risk elevation remained after adjustment for self-harm in the 6 months prior to the discharge date. The relative risk of dying by natural causes was raised in the first 3 months (HR 1.6, 1.3–1.9), with no evidence of elevation during the second year following discharge. Conclusions: There is an additional risk of death by suicide and natural causes for people with SMI who have been recently discharged from inpatient care over and above the general risk among people with the same diagnosis who have not recently been treated as an inpatient. This mortality gap shows the importance of continued focus, following discharge, on individuals who require inpatient care. [ABSTRACT FROM AUTHOR]

Background. The care received by people presenting to hospital following self-harm varies and it is unclear how different types of treatment affect risk of further self-harm. Method. Observational cohort data from the Manchester Self-Harm Project, UK, included 16 456 individuals presenting to an Emergency Department with self-harm between 2003 and 2011. Individuals were followed up for 12 months. We also used data from a smaller cohort of individuals presenting to 31 hospitals in England during a 3-month period in 2010/2011, followed up for 6 months. Propensity score (PS) methods were used to address observed confounding. Missing data were imputed using multiple imputation. Results. Following PS stratification, those who received a psychosocial assessment had a lower risk of repeat hospital attendance for self-harm than those who were not assessed [RR 0.87, 95% confidence interval (CI) 0.80-0.95]. The risk was reduced most among people less likely to be assessed. Following PS matching, we found no associations between risks of repeat self-harm and admission to a medical bed, referral to outpatient psychiatry or admission to a psychiatric bed. We did not find a relationship between psychosocial assessment and repeat self-harm in the 31 centre cohort. Conclusions. This study shows the potential value of using novel statistical techniques in large mental health datasets to estimate treatment effects. We found that specialist psychosocial assessment may reduce the risk of repeat self-harm. This type of routine care should be provided for all individuals who present to hospital after self-harm, regardless of perceived risk. [ABSTRACT FROM AUTHOR]

BackgroundObservations in psychiatric in-patient settings are used to reduce suicide, self-harm, violence and absconding risk. The study aims were to describe the characteristics of in-patients who died by suicide under observation and examine their service-related antecedents.MethodA national consecutive case series in England and Wales (2006–2012) was examined.ResultsThere were 113 suicides by in-patients under observation, an average of 16 per year. Most were under intermittent observation. Five deaths occurred while patients were under constant observation. Patient deaths were linked with the use of less experienced staff or staff unfamiliar with the patient, deviation from procedures and absconding.ConclusionsWe identified key elements of observation that could improve safety, including only using experienced and skilled staff for the intervention and using observation levels determined by clinical need not resources. [ABSTRACT FROM PUBLISHER]

BackgroundJob loss, debt and financial difficulties are associated with increased risk of mental illness and suicide in the general population. Interventions targeting people in debt or unemployed might help reduce these effects.MethodWe searched MEDLINE, Embase, The Cochrane Library, Web of Science, and PsycINFO (January 2016) for randomized controlled trials (RCTs) of interventions to reduce the effects of unemployment and debt on mental health in general population samples. We assessed papers for inclusion, extracted data and assessed risk of bias.ResultsEleven RCTs (n = 5303 participants) met the inclusion criteria. All recruited participants were unemployed. Five RCTs assessed ‘job-club’ interventions, two cognitive behaviour therapy (CBT) and a single RCT assessed each of emotional competency training, expressive writing, guided imagery and debt advice. All studies were at high risk of bias. ‘Job club’ interventions led to improvements in levels of depression up to 2 years post-intervention; effects were strongest among those at increased risk of depression (improvements of up to 0.2–0.3 s.d. in depression scores). There was mixed evidence for effectiveness of group CBT on symptoms of depression. An RCT of debt advice found no effect but had poor uptake. Single trials of three other interventions showed no evidence of benefit.Conclusions‘Job-club’ interventions may be effective in reducing depressive symptoms in unemployed people, particularly those at high risk of depression. Evidence for CBT-type interventions is mixed; further trials are needed. However the studies are old and at high risk of bias. Future intervention studies should follow CONSORT guidelines and address issues of poor uptake. [ABSTRACT FROM PUBLISHER]

BackgroundLittle is known about the precursors of suicide risk among primary-care patients. This study aimed to examine suicide risk in relation to patterns of clinical consultation, psychotropic drug prescribing, and psychiatric diagnoses.MethodNested case-control study in the Clinical Practice Research Datalink (CPRD), England. Patients aged ⩾16 years who died by suicide during 2002–2011 (N = 2384) were matched on gender, age and practice with up to 20 living control patients (N = 46 899).ResultsRisk was raised among non-consulting patients, and increased sharply with rising number of consultations in the preceding year [⩾12 consultations v. 1: unadjusted odds ratio (OR) 6.0, 95% confidence interval (CI) 4.9–7.3]. Markedly elevated risk was also associated with the prescribing of multiple psychotropic medication types (⩾5 types v. 0: OR 62.6, CI 44.3–88.4) and with having several psychiatric diagnoses (⩾4 diagnoses v. 0: OR 31.1, CI 19.3–50.1). Risk was also raised among patients living in more socially deprived localities. The confounding effect of multiple psychotropic drug types largely accounted for the rising risk gradient observed with increasing consultation frequency.ConclusionsA greater proportion of patients with several psychiatric diagnoses, those prescribed multiple psychotropic medication types, and those who consult at very high frequency might be considered for referral to mental health services by their general practitioners. Non-consulters are also at increased risk, which suggests that conventional models of primary care may not be effective in meeting the needs of all people in the community experiencing major psychosocial difficulties. [ABSTRACT FROM PUBLISHER]

Background:Anxiety disorders are assumed to increase suicide risk, although confounding by comorbid psychiatric disorders may be one explanation. This study describes the characteristics of older patients with an anxiety disorder who died by suicide in comparison to younger patients.Method:A 15-year national clinical survey of all suicides in the UK (n = 25,128). Among the 4,481 older patients who died by suicide (≥ 60 years), 209 (4.7%) suffered from a primary anxiety disorder, and 533 (11.9%) from a comorbid anxiety disorder. Characteristics of older (n = 209) and younger (n = 773) patients with a primary anxiety disorder were compared by logistic regression adjusted for sex and living arrangement.Results:Compared to younger patients, older patients with a primary anxiety disorder were more often males and more often lived alone. Although 60% of older patients had a history of psychiatric admissions and 50% of deliberate self-harm, a history of self-harm, violence, and substance misuse was significantly less frequent compared to younger patients, whereas physical health problems and comorbid depressive illness were more common. Older patients were prescribed significantly more psychotropic drugs and received less psychotherapy compared to younger patients.Conclusion:Anxiety disorders are involved in one of every six older patients who died by suicide. Characteristics among patients who died by suicide show severe psychopathology, with a more prominent role for physical decline and social isolation compared to their younger counterparts. Moreover, treatment was less optimal in the elderly, suggesting ageism. These results shed light on the phenomenon of suicide in late-life anxiety disorder and suggest areas where prevention efforts might be focused. [ABSTRACT FROM PUBLISHER]

BackgroundBipolar disorder (BD) has been reported to be associated with high risk of suicide. We aimed to investigate the frequency and characteristics of suicide in people with BD in a national sample.MethodSuicide in BD in England from 1996 to 2009 was explored using descriptive statistics on data collected by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI). Suicide cases with a primary diagnosis of BD were compared to suicide cases with any other primary diagnosis.ResultsDuring the study period 1489 individuals with BD died by suicide, an average of 116 cases/year. Compared to other primary diagnosis suicides, those with BD were more likely to be female, more than 5 years post-diagnosis, current/recent in-patients, to have more than five in-patient admissions, and to have depressive symptoms. In BD suicides the most common co-morbid diagnoses were personality disorder and alcohol dependence. Approximately 40% were not prescribed mood stabilizers at the time of death. More than 60% of BD suicides were in contact with services the week prior to suicide but were assessed as low risk.ConclusionsGiven the high rate of suicide in BD and the low estimates of risk, it is important that health professionals can accurately identify patients most likely to experience poor outcomes. Factors such as alcohol dependence/misuse, personality disorder, depressive illness and current/recent in-patient admission could characterize a high-risk group. Future studies need to operationalize clinically useful indicators of suicide risk in BD. [ABSTRACT FROM AUTHOR]

BackgroundOfficial suicide statistics for England are based on deaths given suicide verdicts and most cases given an open verdict following a coroner's inquest. Previous research indicates that some deaths given accidental verdicts are considered to be suicides by clinicians. Changes in coroners' use of different verdicts may bias suicide trend estimates. We investigated whether suicide trends may be over- or underestimated when they are based on deaths given suicide and open verdicts.MethodPossible suicides assessed by 12 English coroners in 1990/91, 1998 and 2005 and assigned open, accident/misadventure or narrative verdicts were rated by three experienced suicide researchers according to the likelihood that they were suicides. Details of all suicide verdicts given by these coroners were also recorded.ResultsIn 1990/91, 72.0% of researcher-defined suicides received a suicide verdict from the coroner, this decreased to 65.4% in 2005 (ptrend < 0.01); equivalent figures for combined suicide and open verdicts were 95.4% (1990/91) and 86.7% (2005). Researcher-defined suicides with a verdict of accident/misadventure doubled over that period, from 4.6% to 9.1% (p < 0.01). Narrative verdict cases rose from zero in 1990/91 to 25 in 2005 (4.2% of researcher-defined suicides that year). In 1998 and 2005, 50.0% of the medicine poisoning deaths given accidental/misadventure verdicts were rated as suicide by the researchers.ConclusionsBetween 1990/91 and 2005, the proportion of researcher-defined suicides given a suicide verdict by coroners decreased, largely due to an increased use of accident/misadventure verdicts, particularly for deaths involving poisoning. Consideration should be given to the inclusion of ‘accidental’ deaths by poisoning with medicines in the statistics available for monitoring suicides rates. [ABSTRACT FROM AUTHOR]

BackgroundPsychiatric in-patients are at high risk of suicide. Recent reductions in bed numbers in many countries may have affected this risk but few studies have specifically investigated temporal trends. We aimed to explore trends in psychiatric in-patient suicide over time.MethodA prospective study of all patients admitted to National Health Service (NHS) in-patient psychiatric care in England (1997–2008). Suicide rates were determined using National Confidential Inquiry and Hospital Episode Statistics (HES) data.ResultsOver the study period there were 1942 psychiatric in-patient suicides. Between the first 2 years of the study (1997, 1998) and the last 2 years (2007, 2008) the rate of in-patient suicide fell by nearly one-third from 2.45 to 1.68 per 100 000 bed days. This fall in rate was observed for males and females, across ethnicities and diagnoses. It was most marked for patients aged 15–44 years. Rates also fell for the most common suicide methods, particularly suicide by hanging on the ward (a 59% reduction). Although the number of post-discharge suicides fell, the rate of post-discharge suicide may have increased by 19%. The number of suicide deaths in those under the care of crisis resolution/home treatment teams has increased in recent years to approximately 160 annually.ConclusionsThe rate of suicide among psychiatric in-patients in England has fallen considerably. Possible explanations include falling general population rates, changes in the at-risk population or improved in-patient safety. However, a transfer of risk to the period after discharge or other clinical settings such as crisis resolution teams cannot be ruled out. [ABSTRACT FROM PUBLISHER]

Background. Self-harm is a common reason for Emergency Department (ED) attendance. We aimed to develop a clinical tool to help identify patients at higher risk of repeat self-harm, or suicide, within 6 months of an ED self-harm presentation. Method. The tool, the ReACT Self-Harm Rule, was derived using multicentre data from a prospective cohort study. Binary recursive partitioning was applied to data from two centres, and data from a separate centre were used to test the tool. There were 29 571 self-harm presentations to five hospital EDs between January 2003 and June 2007, involving 18 680 adults aged ≥ 16 years. We estimated sensitivity, specificity and positive and negative predictive values to measure the performance of the tool. Results. A self-harm presentation was classified as higher risk if at least one of the following factors was present: recent self-harm (in the past year), living alone or homelessness, cutting as a method of harm and treatment for a current psychiatric disorder. The rule performed with 95% sensitivity [95% confidence interval (CI) 94-95] and 21% specificity (95% CI 21-22), and had a positive predictive value of 30% (95% CI 30-31) and a negative predictive value of 91 % (95% CI 90-92) in the derivation centres; it identified 83/92 of all subsequent suicides. Conclusions. The ReACT Self-Harm Rule might be used as a screening tool to inform the process of assessing self- harm presentations to ED. The four risk factors could also be used as an adjunct to in-depth psychosocial assessment to help guide risk formulation. The use of multicentre data helped to maximize the generalizability of the tool, but we need to further verify its external validity in other localities. [ABSTRACT FROM AUTHOR]

BackgroundMortality, including suicide and accidents, is elevated in self-harm populations. Although risk factors for suicide following self-harm are often investigated, rarely have those for accidents been studied. Our aim was to compare risk factors for suicide and accidents.MethodA prospective cohort (n=30 202) from the Multicentre Study of Self-harm in England, 2000–2007, was followed up to 2010 using national death registers. Risk factors for suicide (intentional self-harm and undetermined intent) and accidents (narcotic poisoning, non-narcotic poisoning, and non-poisoning) following the last hospital presentation for self-harm were estimated using Cox models.ResultsDuring follow-up, 1833 individuals died, 378 (20.6%) by suicide and 242 (13.2%) by accidents. Independent predictors of both suicide and accidents were: male gender, age ⩾35 years (except accidental narcotic poisoning) and psychiatric treatment (except accidental narcotic poisoning). Factors differentiating suicide from accident risk were previous self-harm, last method of self-harm (twofold increased risks for cutting and violent self-injury versus self-poisoning) and mental health problems. A risk factor specific to accidental narcotic poisoning was recreational/illicit drug problems, and a risk factor specific to accidental non-narcotic poisoning and non-poisoning accidents was alcohol involvement with self-harm.ConclusionsThe similarity of risk factors for suicide and accidents indicates common experiences of socio-economic disadvantage, life problems and psychopathology resulting in a variety of self-destructive behaviour. Of factors associated with the accidental death groups, those for non-narcotic poisoning and other accidents were most similar to suicide; differences seemed to be related to criteria coroners use in reaching verdicts. Our findings support the idea of a continuum of premature death. [ABSTRACT FROM PUBLISHER]

BackgroundFew controlled studies have specifically investigated aspects of mental health care in relation to suicide risk among recently discharged psychiatric patients. We aimed to identify risk factors, including variation in healthcare received, for suicide within 3 months of discharge.MethodWe conducted a national population-based case-control study of 238 psychiatric patients dying by suicide within 3 months of hospital discharge, matched on date of discharge to 238 living controls.ResultsForty-three per cent of suicides occurred within a month of discharge, 47% of whom died before their first follow-up appointment. The first week and the first day after discharge were particular high-risk periods. Risk factors for suicide included a history of self-harm, a primary diagnosis of affective disorder, recent last contact with services and expressing clinical symptoms at last contact with staff. Suicide cases were more likely to have initiated their own discharge and to have missed their last appointment with services. Patients who were detained for compulsory treatment at last admission, or who were subject to enhanced levels of aftercare, were less likely to die by suicide.ConclusionsThe weeks after discharge from psychiatric care represent a critical period for suicide risk. Measures that could reduce risk include intensive and early community follow-up. Assessment of risk should include established risk factors as well as current mental state and there should be clear follow-up procedures for those who have self-discharged. Recent detention under the Mental Health Act and current use of enhanced levels of aftercare may be protective. [ABSTRACT FROM PUBLISHER]

Background. Few controlled studies have investigated factors associated with suicide in current in-patients. We aimed to identify psychosocial, behavioural and clinical risk factors, including variations in care, for in-patient suicide.Method. We conducted a national population-based case-control study of people who died by suicide between 1 April 1999 and 31 December 2000 while in psychiatric in-patient care in England. Cases were 222 adult mental health in-patients who died by suicide matched on date of death with 222 living controls.Results. Nearly a quarter of suicides took place within the first week of admission; most of these died on the ward or after absconding. After the first week, however, most suicides occurred away from the ward, the majority of patients having left the ward with staff agreement. Previous deliberate self-harm, recent adverse life events, symptoms of mental illness at last contact with staff and a co-morbid psychiatric disorder were associated with increased risk for suicide. Being off the ward without staff agreement was a particularly strong predictor. Those patients who were detained for compulsory treatment were less likely to die by suicide. Independent predictors of in-patient suicide were male sex, a primary diagnosis of affective disorder and a history of self-harm. Being unemployed or on long-term sick leave appeared to be independently protective.Conclusion. Prevention of in-patient suicide should emphasize adequate treatment of affective disorder, vigilance in the first week of admission and regular risk assessments during recovery and prior to granting leave. Use of compulsory treatment may reduce risk. [ABSTRACT FROM AUTHOR]

Background. Psychiatric in-patients are at particularly high risk of suicide but few studies have investigated trends in in-patient suicide over time.Method. We conducted a prospective study of all patients admitted to National Health Service (NHS) in-patient psychiatric care in England (1997-2003). The study was carried out as part of the National Confidential Inquiry into Suicide. The main outcome measure was death by suicide. Suicide rates were determined using Hospital Episode Statistics (HES) as the denominator.Results. Between the first 2 years of the study (1997 and 1998) and the last 2 years of the study (2002 and 2003) the annual number of in-patient deaths from suicide fell from 187 to 156 (a 17% reduction). The rate of in-patient suicide fell by between 9% and 28% depending on which denominator was used. This fall was observed for both males and females, and was most marked for those aged 15-44 years. Reductions were also observed for the three most common methods of death (hanging, jumping, poisoning), but the trend for hanging did not reach statistical significance. Although the number of post-discharge suicides fell, the risk of post-discharge suicide (using admissions as a denominator) may have increased by as much as 10% during the study period.Conclusion. The rate of suicide among psychiatric in-patients appears to have fallen. The fall may reflect falling general population rates, changes in in-patient case mix, service improvements, or a transfer of risk to the post-discharge period. Services need to be aware of the importance of providing high quality aftercare following discharge from hospital. [ABSTRACT FROM AUTHOR]

BACKGROUND: Despite extensive research, the reasons why patients consult their doctors are unclear. The aim of the current study was to identify the psychosocial and illness related factors that independently predicted primary care consultation over a 5-year period. METHOD: We carried out a prospective, population-based cohort study with three waves of data collection by postal questionnaire in one general practice in Greater Manchester (UK). Consultation data were sought from primary care records on a random subsample of 800 adult patients. The main outcome measure was the number of consultations (including surgery and home visits) over the 5 years of the study as determined by raters blind to questionnaire responses. Questionnaire measures included the 12-item version of the General Health Questionnaire, the Illness Attitude Scales, a somatic symptom scale, a fatigue scale, a functional assessment of disability. RESULTS: Consultation data were obtained on 738 patients (92% of selected subjects), who accounted for 12182 consultations. Negative illness attitudes, the presence of physical and psychiatric disorder, health anxiety, changes in psychological distress, reported physical symptoms and demographic factors such as age and sex were independently associated with consultation over a 5-year period. These variables together accounted for a difference of ten consultations per year between groups. CONCLUSION: Consultation in primary care is a complex behaviour with a complex aetiology. Terms such as 'frequent attenders' may be less helpful than recognizing a number of dimensions that operate across the whole spectrum of consultation frequency. Future research should consider the wider context of consultation. [ABSTRACT FROM AUTHOR]

A case of transient amnesia is described in which a patient reported memory loss for five days, during which he had wandered extensively. Analysis showed that he did not have selective amnesia for the public events which had occurred during the five days for which he professed memory loss. This finding was incompatible with our case having a neurologically based global memory disorder during the fugue state. These findings offer support for a distinction between personal and public episodic memory. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Psychiatric in-patient care and suicide in England, 1997 to 2008 : a longitudinal study," by N. Kapur and colleagues published online in the 17th May 2012 issue.

A letter to the editor is presented about the linkage of self-harm to suicide.

A response by O. Bennewith and colleagues to a letter to the editor about their article "Suicide by hanging: multicentre study based on coroners' record in England," in the 2005 issue, is presented.

Recent studies suggest an evidence for a “male depressive syndrome” in patients with major depressive disorder. Because males are markedly overrepresented among suicide victims and the opposite is true for suicide attempters, we investigated the rate and global severity of Gotland Male Depression as measured by the Gotland Male Depression scale in 86 suicide victims (74 males, 12 females), 86 suicide attempters (21 males, 65 females) with current DSM-IV major depressive episode and in 144 normal controls (116 males, 28 females). The rate of Gotland “Male” Depression (total score of 13 or more) was significantly higher in depressed suicide victims (98%) and in depressed suicide attempters (93%) than in normal controls (2%, p=0.00001). Among depressed suicide victims 100% of males and 83% of females have had Gotland “Male” Depression (p=0.02) while the same figures among the depressed suicide attempters were 91% and 94%, respectively (not significant). The total Gotland Male Depression scores were significantly higher in depressive suicide victims (22.26) and depressive suicide attempters (23.23) than in normal controls (4.01, p=0.00001 and p=0.0001, respectively), with significant gender differences only among depressed suicide victims (males: 22.85, females: 18.58, p=0.009) and normal controls (males: 4.33, females: 2.71, p=0.05). However, since male and female depressed inpatients do not show clinically significant difference in their mean total scores on Gotland scale symptoms (11.99 vs 12.04, Möller-Leimkühler et al, 2004), it would be premature to conclude from our present findings that compared to nonsuicidal female depressives, suicidal female depressives have male-type depression profile. [Copyright &y& Elsevier]

Background: Domestic abuse is a significant risk factor for self-harm and suicide. A large proportion of people presenting to healthcare services following self-harm have experienced domestic abuse. In the UK, routine enquiry for domestic abuse is recommended for people who present having self-harmed, but evidence indicates that this is not happening., Aims: An exploratory qualitative study to explore liaison psychiatry staff experiences of asking about domestic abuse, including the barriers and challenges to asking., Method: Semi-structured qualitative interviews with active adult liaison psychiatry staff in the UK. Recruitment was via online platforms and professional networks. A reflexive thematic analysis of the narratives was carried out., Results: Fifteen participants were interviewed across a variety of disciplines (ten nurses, four doctors, one social worker). The generated themes include the following: asking about domestic abuse - the tension between knowing and doing; 'delving deeper' and the fear of making things worse; the entanglement of shame, blame and despondency; domestic abuse was different from other clinical problems (mental illness/substance misuse); and biases, myths and misassumptions guiding practice. Participants indicated the need for better training and education, and clear protocols for eliciting and acting on disclosures., Conclusion: There is a clear need to improve the support offered to victim-survivors of domestic abuse who self-harm and present to healthcare services. National implementation of education and training to better equip liaison psychiatry teams with the skills and knowledge to sensitively support victim-survivors of domestic abuse is required.

Background: Psychiatric in-patients have a greatly elevated risk of suicide. We aimed to examine trends in in-patient suicide rates and determine if characteristics of in-patients who died by suicide have changed over time., Methods: We identified all in-patients in England who died by suicide between 2009 and 2020 from the National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide rates were calculated using data from Hospital Episodes Statistics., Results: The rate of in-patient suicide per 100 000 bed days fell by 41.9% between 2009-2011 and 2018-2020. However, since 2016 the rate has remained static with no significant fall. Rates fell in men, those aged 30-59, and those with schizophrenia and other delusional disorders or personality disorder. Rates also fell for suicide by hanging (including hanging on the ward) and jumping. No falls were seen in suicide rates among women, younger and older age groups, and those with affective disorder. There was no indication of a transfer of risk to the post-discharge period or to home treatment/crisis care. More in-patients in the latter part of the study were aged under 25, were on authorised leave, and had psychiatric comorbidity., Conclusions: In-patient suicide has significantly fallen since 2009, suggesting patient safety may have improved. The recent slowdown in the fall in rates, however, highlights that renewed preventative efforts are needed. These should include a greater focus on women, younger and older patients, and those with affective disorder. Careful reviews prior to granting leave are important to ensure a safe transition into the community.

Background: People under the care of mental health services are at increased risk of suicide. Existing studies are small in scale and lack comparisons., Aims: To identify opportunities for suicide prevention and underpinning data enhancement in people with recent contact with mental health services., Method: This population-based study includes people who died by suicide in the year following a mental health services contact in Wales, 2001-2015 (cases), paired with similar patients who did not die by suicide (controls). We linked the National Confidential Inquiry into Suicide and Safety in Mental Health and the Suicide Information Database - Cymru with primary and secondary healthcare records. We present results of conditional logistic regression., Results: We matched 1031 cases with 5155 controls. In the year before their death, 98.3% of cases were in contact with healthcare services, and 28.5% presented with self-harm. Cases had more emergency department contacts (odds ratio 2.4, 95% CI 2.1-2.7) and emergency hospital admissions (odds ratio 1.5, 95% CI 1.4-1.7), but fewer primary care contacts (odds ratio 0.7, 95% CI 0.6-0.9) and out-patient appointments (odds ratio 0.2, 95% CI 0.2-0.3) than controls. Odds ratios were larger in females than males for injury and poisoning (odds ratio: 3.3 (95% CI 2.5-4.5) v. 2.6 (95% CI 2.1-3.1))., Conclusions: We may be missing existing opportunities to intervene, particularly in emergency departments and hospital admissions with self-harm presentations and with unattributed self-harm, especially in females. Prevention efforts should focus on strengthening routine care contacts, responding to emergency contacts and better self-harm care. There are benefits to enhancing clinical audit systems with routinely collected data.

Background: The aetiology of dual harm (co-occurring self-harm and violence towards others) is poorly understood because most studies have investigated self-harm and violence separately. We aimed to examine childhood risk factors for self-harm, violence, and dual harm, including the transition from engaging in single harm to dual harm., Methods: Data from the Avon Longitudinal Study of Parents and Children, a UK-based birth cohort study, were used to estimate prevalence of self-reported engagement in self-harm, violence, and dual harm at ages 16 and 22 years. Risk ratios were calculated to indicate associations across various self-reported childhood risk factors and risks of single and dual harm, including the transition from single harm at age 16 years to dual harm at age 22., Results: At age 16 years, 18.1% of the 4176 cohort members had harmed themselves, 21.1% had engaged in violence towards others and 3.7% reported dual harm. At age 22 the equivalent prevalence estimates increased to 24.2, 25.8 and 6.8%, respectively. Depression and other mental health difficulties, drug and alcohol use, witnessing self-harm and being a victim of, or witnessing, violence were associated with higher risks of transitioning from self-harm or violence at age 16 to dual harm by age 22., Conclusions: Prevalence of dual harm doubled from age 16 to 22 years, highlighting the importance of early identification and intervention during this high-risk period. Several childhood psychosocial risk factors associated specifically with dual harm at age 16 and with the transition to dual harm by age 22 have been identified.

In this editorial we, as members of the 2022 NICE Guideline Committee, highlight and discuss what, in our view, are the key guideline recommendations (generated through evidence synthesis and consensus) for mental health professionals when caring for people after self-harm, and we consider some of the implementation challenges.

Background: Psychological therapies following an episode of self-harm should happen quickly to ensure patients receive the care they need and to reduce the likelihood of repetition., Aims: We sought to explore patients' subjective experience of accessing psychological therapies following self-harm and their views on improving practice., Method: Between March and November 2019, we recruited 128 patients and 23 carers aged 18 years or over from 16 English mental health trusts, from community organisations and via social media. Thematic analyses were used to interpret the data., Results: Participants reported long waiting times, multiple failed promises and rejection when trying to access psychological therapies following self-harm. Poor communication and information provision contributed to uncertainty, worsening mental health and further self-harm. Other barriers included: lack of tailored interventions, stigmatising responses, use of exclusionary thresholds to access services, and punitive approaches to treating these patients. Participant recommendations to improve access to psychological therapies included: (a) the importance of compassionate and informed staff; (b) having timely access to aftercare from well-funded and well-resourced teams; (c) continuity of care, improved communication, and support during waiting times and while navigating the referral process; (d) greater information on the availability and benefits of psychological therapies; and (e) greater choice and flexibility over interventions., Conclusion: Our findings identify long waiting times and inadequate service provision as barriers to high-quality and safe aftercare for patients who have self-harmed. Consistent with clinical guidelines, all patients should receive prompt aftercare and access to tailored psychological treatments following a self-harm episode.

Background: Family involvement has been identified as a key aspect of clinical practice that may help to prevent suicide., Aims: To investigate how families can be effectively involved in supporting a patient accessing crisis mental health services., Method: A multi-site ethnographic investigation was undertaken with two crisis resolution home treatment teams in England. Data included 27 observations of clinical practice and interviews with 6 patients, 4 family members, and 13 healthcare professionals. Data were analysed using framework analysis., Results: Three overarching themes described how families and carers are involved in mental healthcare. Families played a key role in keeping patients safe by reducing access to means of self-harm. They also provided useful contextual information to healthcare professionals delivering the service. However, delivering a home-based service can be challenging in the absence of a supportive family environment or because of practical problems such as the lack of suitable private spaces within the home. At an organisational level, service design and delivery can be adjusted to promote family involvement., Conclusions: Findings from this study indicate that better communication and dissemination of safety and care plans, shared learning, signposting to carer groups and support for carers may facilitate better family involvement. Organisationally, offering flexible appointment times and alternative spaces for appointments may help improve services for patients.

Background: We compared the risk of death by suicide following hospital presentation for self-harm according to site of self-cut/stab., Method: We included 54 999 self-harm presentations (involving 31 419 individuals) to hospitals in the Multicentre Study of Self-harm in England (1/1/2004-31/12/2014), with mortality follow-up to 31/12/2019. Information on method of self-harm was obtained through monitoring in hospitals. Information about mortality was obtained through linkage with NHS Digital. We assessed the association of site of self-cut with death by suicide using mixed effect models., Results: In total, 10 790 (19.6%) hospital presentations involved self-cutting/stabbing, 7489 of which (69.4%) were due to laceration to the arm/wrist alone, 1846 episodes (17.1%) involved cutting elsewhere on the body, and 1455 (13.5%) were due to laceration to unknown site. Controlling for confounders, presentation to a hospital following self-cut/stab to bodily parts other than wrist/arm was associated with greater chance of subsequent suicide relative to presentation after self-poisoning alone [adjusted odds ratio (aOR) 1.75, 95% confidence interval (CI) 1.03-2.96, p = 0.038]. The likelihood of suicide after presentation for cutting/stabbing the wrist/arm alone was comparable to that of patients who had self-poisoned alone. Presentations after laceration involving the neck were associated with a four-fold greater chance of subsequent suicide relative to self-poisoning (aOR 4.09, 95% CI 1.80-9.30, p = 0.001)., Conclusions: Patients who attend hospital after self-cutting/stabbing are a heterogeneous group in terms of characteristics, methods of cutting/stabbing and risk of subsequent suicide. Risk of suicide is greater in individuals who self-cut/stab to parts of the body other than the wrist or arm, especially the neck.

Background: Timely provision of aftercare following self-harm may reduce risks of repetition and premature death, but existing services are frequently reported as being inadequate., Aims: To explore barriers and facilitators to accessing aftercare and psychological therapies for patients presenting to hospital following self-harm, from the perspective of liaison psychiatry practitioners., Method: Between March 2019 and December 2020, we interviewed 51 staff members across 32 liaison psychiatry services in England. We used thematic analyses to interpret the interview data., Results: Barriers to accessing services may heighten risk of further self-harm for patients and burnout for staff. Barriers included: perceived risk, exclusionary thresholds, long waiting times, siloed working and bureaucracy. Strategies to increase access to aftercare included: (a) improving assessments and care plans via input from skilled staff working in multidisciplinary teams (e.g. including social workers and clinical psychologists); (b) supporting staff to focus on assessments as therapeutic intervention; (c) probing boundaries and involving senior staff to negotiate risk and advocate for patients; and (d) building relationships and integration across services., Conclusions: Our findings highlight practitioners' views on barriers to accessing aftercare and strategies to circumvent some of these impediments. Provision of aftercare and psychological therapies as part of the liaison psychiatry service were deemed as an essential mechanism for optimising patient safety and experience and staff well-being. To close treatment gaps and reduce inequalities, it is important to work closely with staff and patients, learn from experiences of good practice and implement change more widely across services.

Background: Evidence on the impact of the pandemic on healthcare presentations for self-harm has accumulated rapidly. However, existing reviews do not include studies published beyond 2020., Aims: To systematically review evidence on presentations to health services following self-harm during the COVID-19 pandemic., Method: A comprehensive search of databases (WHO COVID-19 database; Medline; medRxiv; Scopus; PsyRxiv; SocArXiv; bioRxiv; COVID-19 Open Research Dataset, PubMed) was conducted. Studies published from 1 January 2020 to 7 September 2021 were included. Study quality was assessed with a critical appraisal tool., Results: Fifty-one studies were included: 57% (29/51) were rated as 'low' quality, 31% (16/51) as 'moderate' and 12% (6/51) as 'high-moderate'. Most evidence (84%, 43/51) was from high-income countries. A total of 47% (24/51) of studies reported reductions in presentation frequency, including all six rated as high-moderate quality, which reported reductions of 17-56%. Settings treating higher lethality self-harm were overrepresented among studies reporting increased demand. Two of the three higher-quality studies including study observation months from 2021 reported reductions in self-harm presentations. Evidence from 2021 suggests increased numbers of presentations among adolescents, particularly girls., Conclusions: Sustained reductions in numbers of self-harm presentations were seen into the first half of 2021, although this evidence is based on a relatively small number of higher-quality studies. Evidence from low- and middle-income countries is lacking. Increased numbers of presentations among adolescents, particularly girls, into 2021 is concerning. Findings may reflect changes in thresholds for help-seeking, use of alternative sources of support and variable effects of the pandemic across groups.

Background: Evidence for risk of dying by suicide and other causes following discharge from in-patient psychiatric care throughout adulthood is sparse., Aims: To estimate risks of all-cause mortality, natural and external-cause deaths, suicide and accidental, alcohol-specific and drug-related deaths in working-age and older adults within a year post-discharge., Method: Using interlinked general practice, hospital, and mortality records in the Clinical Practice Research Datalink we delineated a cohort of discharged adults in England, 2001-2018. Each patient was matched to up to 20 general population comparator patients. Cumulative incidence (absolute risks) and hazard ratios (relative risks) were estimated separately for ages 18-64 and ≥65 years with additional stratification by gender and practice-level deprivation., Results: The 1-year cumulative incidence of dying post-discharge was 2.1% among working-age adults (95% CI 2.0-2.3) and 14.1% (95% CI 13.6-14.5) among older adults. Suicide risk was particularly elevated in the first 3 months, with hazard ratios of 191.1 (95% CI 125.0-292.0) among working-age adults and 125.4 (95% CI 52.6-298.9) in older adults. Older patients were vulnerable to dying by natural causes within 3 months post-discharge. Risk of dying by external causes was greater among discharged working-age adults in the least deprived areas. Relative risk of suicide in discharged working-age women relative to their general population peers was double the equivalent male risk elevation., Conclusions: Recently discharged adults at any age are at increased risk of dying from external and natural causes, indicating the importance of close monitoring and provision of optimal support to all such patients, particularly during the first 3 months post-discharge.

Background: Psychological models of suicidal experiences are largely based on cross-sectional or long-term prospective data with follow-up intervals typically greater than 1 year. Recent time-series analyses suggest that these models may not account for fluctuations in suicidal thinking that occur within a period of hours and/or days., Aims: We explored whether previously posited causal relationships between defeat, entrapment and suicidal ideation accounted for temporal associations between these experiences at small time intervals from 3 to 12 h., Method: Participants ( N = 51) completed an ecological momentary assessment (EMA) study, comprising repeated assessments at semi-random time points up to six times per day for 1 week, resulting in 1852 completed questionnaires. Multilevel vector autoregression was used to calculate temporal associations between variables at different time intervals (i.e. 3 to 12 h between measurements)., Results: The results showed that entrapment severity was temporally associated with current and later suicidal ideation, consistently over these time intervals. Furthermore, entrapment had two-way temporal associations with defeat and suicidal ideation at time intervals of approximately 3 h. The residual and contemporaneous network revealed significant associations between all variables, of which the association between entrapment and defeat was the strongest., Conclusions: Although entrapment is key in the pathways leading to suicidal ideation over time periods of months, our results suggest that entrapment may also account for the emergence of suicidal thoughts across time periods spanning a few hours.

Background: People who experience homelessness are thought to be at high risk of suicide, but little is known about self-harm in this population., Aims: To examine characteristics and outcomes in people experiencing homelessness who presented to hospital following self-harm., Method: Data were collected via specialist assessments and/or hospital patient records from emergency departments in Manchester, Oxford and Derby, UK. Data were collected from 1 January 2000 to 31 December 2016, with mortality follow-up via data linkage with NHS Digital to 31 December 2019. Trend tests estimated change in self-harm over time; descriptive statistics described characteristics associated with self-harm. Twelve-month repetition and long-term mortality were analysed using Cox proportional hazards models and controlled for age and gender., Results: There were 4841 self-harm presentations by 3270 people identified as homeless during the study period. Presentations increased after 2010 (IRR = 1.09, 95% CI 1.04-1.14, P < 0.001). People who experienced homelessness were more often men, White, aged under 54 years, with a history of previous self-harm and contact with psychiatric services. Risk of repetition was higher than in domiciled people (HR = 2.05, 95% CI 1.94-2.17, P < 0.001), as were all-cause mortality (HR = 1.45, 95% CI 1.32-1.59. P < 0.001) and mortality due to accidental causes (HR = 2.93, 95% CI 2.41-3.57, P < 0.001)., Conclusions: People who self-harm and experience homelessness have more complex needs and worse outcomes than those who are domiciled. Emergency department contact presents an opportunity to engage people experiencing homelessness with mental health, drug and alcohol, medical and housing services, as well as other sources of support.

Background: Guidance in England recommends psychosocial assessment when presenting to hospital following self-harm but adherence is variable. There is some evidence suggesting that psychosocial assessment is associated with lower risk of subsequent presentation to hospital for self-harm, but the potential cost-effectiveness of psychosocial assessment for hospital-presenting self-harm is unknown., Methods: A three-state four-cycle Markov model was used to assess cost-effectiveness of psychosocial assessment after self-harm compared with no assessment over 2 years. Data on risk of subsequent self-harm and hospital costs of treating self-harm were drawn from the Multicentre Study of Self-Harm in England, while estimates of effectiveness of psychosocial assessment on risk of self-harm, quality of life, and other costs were drawn from literature. Incremental cost-effectiveness ratios (ICERs) for cost per Quality Adjusted Life Year (QALY) gained were estimated. Parameter uncertainty was addressed in univariate and probabilistic sensitivity analyses., Results: Cost per QALY gained from psychosocial assessment was £10,962 (95% uncertainty interval [UI] £15,538-£9,219) from the National Health Service (NHS) perspective and £9,980 (95% UI £14,538-£6,938) from the societal perspective. Results were generally robust to changes in model assumptions. The probability of the ICER being below £20,000 per QALY gained was 78%, rising to 91% with a £30,000 threshold., Conclusions: Psychosocial assessment as implemented in the English NHS is likely to be cost-effective. This evidence could support adherence to NICE guidelines. However, further evidence is needed about the precise impacts of psychosocial assessment on self-harm repetition and costs to individuals and their families beyond immediate hospital stay.

Background: Homicide rates have fallen markedly in the UK over the past decade. There has been little research on whether homicides by people with mental disorder have contributed to this downward trend. Furthermore, there is limited information on trends in court outcomes for people with mental disorder who commit homicide., Aims: To examine trends in general population homicide and homicide by people with mental disorder, and to explore court outcome., Method: We conducted a national, consecutive case series of homicide in England and Wales (1997-2015). Data were received from the Home Office Statistics Unit of Home Office Science. Clinical information was obtained from psychiatric reports and mental health services., Results: There has been a fall in the homicide rate in England and Wales since 2008. Despite this, the relative contribution of mental disorder as a proportion of all homicide has increased. Our findings also showed the inappropriate management of people with serious mental illness convicted of homicide. Of those who committed homicide and were diagnosed with schizophrenia, a third were imprisoned, and there was a marked fall in hospital order referrals. We found this to be linked to substance misuse comorbidity., Conclusions: The proportional increase in homicide by people with schizophrenia suggests more complex factors may be driving rates, such as substance misuse. Addressing substance misuse comorbidity and maintaining engagement with services may help prevent patient homicide. Despite their complex needs, people with serious mental illness continue to be imprisoned. Improvements in assessment and the timely transfer of prisoners to health services are required.

Background: Individuals attending emergency departments following self-harm have increased risks of future self-harm. Despite the common use of risk scales in self-harm assessment, there is growing evidence that combinations of risk factors do not accurately identify those at greatest risk of further self-harm and suicide., Aims: To evaluate and compare predictive accuracy in prediction of repeat self-harm from clinician and patient ratings of risk, individual risk-scale items and a scale constructed with top-performing items., Method: We conducted secondary analysis of data from a five-hospital multicentre prospective cohort study of participants referred to psychiatric liaison services following self-harm. We tested predictive utility of items from five risk scales: Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS, Modified SAD PERSONS, Barratt Impulsiveness Scale and clinician and patient risk estimates. Area under the curve (AUC), sensitivity, specificity, predictive values and likelihood ratios were used to evaluate predictive accuracy, with sensitivity analyses using classification-tree regression., Results: A total of 483 self-harm episodes were included, and 145 (30%) were followed by a repeat presentation within 6 months. AUC of individual items ranged from 0.43-0.65. Combining best performing items resulted in an AUC of 0.56. Some individual items outperformed the scale they originated from; no items were superior to clinician or patient risk estimations., Conclusions: No individual or combination of items outperformed patients' or clinicians' ratings. This suggests there are limitations to combining risk factors to predict risk of self-harm repetition. Risk scales should have little role in the management of people who have self-harmed.

Background: Longitudinal studies of patterns of healthcare contacts in those who die by suicide to identify those at risk are scarce., Aims: To examine type and timing of healthcare contacts in those who die by suicide., Method: A population-based electronic case-control study of all who died by suicide in Wales, 2001-2017, linking individuals' electronic healthcare records from general practices, emergency departments and hospitals. We used conditional logistic regression to calculate odds ratios, adjusted for deprivation. We performed a retrospective continuous longitudinal analysis comparing cases' and controls' contacts with health services., Results: We matched 5130 cases with 25 650 controls (5 per case). A representative cohort of 1721 cases (8605 controls) were eligible for the fully linked analysis. In the week before their death, 31.4% of cases and 15.6% of controls contacted health services. The last point of contact was most commonly associated with mental health and most often occurred in general practices. In the month before their death, 16.6 and 13.0% of cases had an emergency department contact and a hospital admission respectively, compared with 5.5 and 4.2% of controls. At any week in the year before their death, cases were more likely to contact healthcare services than controls. Self-harm, mental health and substance misuse contacts were strongly linked with suicide risk, more so when they occurred in emergency departments or as emergency admissions., Conclusions: Help-seeking occurs in those at risk of suicide and escalates in the weeks before their death. There is an opportunity to identify and intervene through these contacts.

This editorial considers whether the quality of care for people who present to clinical services in the UK following self-harm has improved or stagnated. Some real progress has been made in the areas of service provision and research, and self-harm has never had a higher priority in policy terms. However, major gaps remain. We need to enhance people's experience of services and improve access to high-quality assessment and aftercare.

Background: Individual- and area-level risk factors for suicide are relatively well-understood but the role of macro social factors such as alienation, social fragmentation or 'anomie' is relatively underresearched. Voting choice in the 2016 referendum on the UK's membership of the European Union (EU) provides a potential measure of anomie., Aims: To examine associations between percentage 'Leave' votes in the EU referendum and suicide rates in 2015-2017, the period just prior to, and following, the referendum., Method: National cross-sectional ecological study of 315 English local authority populations. Associations between voting choice in the EU referendum and age-standardised suicide rates, averaged for the years 2015, 2016 and 2017, were examined., Results: Overall there was a weak, but statistically significant, positive correlation between the local authority-level percentage 'Leave' vote in 2016 and the suicide rate 2015-2017: Pearson's correlation coefficient, r = 0.17; P = 0.003. This relationship was explained by populations having an older age distribution, being more deprived and lacking ethnic diversity. However, there was divergence (likelihood ratio test for interaction, χ2 = 7.2, P = 0.007) in the observed associations between London and the provincial regions with Greater London having a moderately strong negative association (r = -0.40; P = 0.02) and the rest of England a weak positive association (r = 0.17; P = 0.004)., Conclusions: Deprivation, older age distribution and a lack of ethnic diversity seems to explain raised suicide risk in Brexit-voting communities. A greater sense of alienation among people feeling 'left behind'/'left out' may have had some influence too, although multilevel modelling of individual- versus area-level data are needed to examine these complex relationships. The incongruent ecological relationship observed for London likely reflect its distinct social, economic and health context.

Background: Worldwide suicide is commonest in young people and in many countries, including the UK, suicide rates in young people are rising., Aims: To investigate the stresses young people face before they take their lives, their contact with services that could be preventative and whether these differ in girls and boys., Method: We identified a 3-year UK national consecutive case series of deaths by suicide in people aged 10-19, based on national mortality data. We extracted information on the antecedents of suicide from official investigations, primarily inquests., Results: Between 2014 and 2016, there were 595 suicides by young people, almost 200 per year; 71% were male (n = 425). Suicide rates increased from the mid-teens, most deaths occurred in those aged 17-19 (443, 74%). We obtained data about the antecedents of suicide for 544 (91%). A number of previous and recent stresses were reported including witnessing domestic violence, bullying, self-harm, bereavement (including by suicide) and academic pressures. These experiences were generally more common in girls than boys, whereas drug misuse (odds ratio (OR) = 0.54, 95% CI 0.35-0.83, P = 0.006) and workplace problems (OR 0.52, 95% CI 0.28-0.96, P = 0.04) were less common in girls. A total of 329 (60%) had been in contact with specialist children's services, and this was more common in girls (OR 1.86, 95% CI 1.19-2.94, P = 0.007)., Conclusions: There are several antecedents to suicide in young people, particularly girls, which are important in a multiagency approach to prevention incorporating education, social care, health services and the third sector. Some of these may also have contributed to the recent rise.

Background: Fatigue syndromes (FSs) affect large numbers of individuals, yet evidence from epidemiological studies on adverse outcomes, such as premature death, is limited., Methods: Cohort study involving 385 general practices in England that contributed to the Clinical Practice Research Datalink (CPRD) with linked inpatient Hospital Episode Statistics (HES) and Office for National Statistics (ONS) cause of death information. A total of 10 477 patients aged 15 years and above, diagnosed with a FS during 2000-2014, were individually matched with up to 20 comparator patients without a history of having a FS. Prevalence ratios (PRs) were estimated to compare the FS and comparison cohorts on clinical characteristics. Adjusted hazard ratios (HRs) for subsequent adverse outcomes were estimated from stratified Cox regression models., Results: Among patients diagnosed with FSs, we found elevated baseline prevalence of: any psychiatric illness (PR 1.77; 95% CI 1.72-1.82), anxiety disorders (PR 1.92; 1.85-1.99), depression (PR 1.89; 1.83-1.96), psychotropic prescriptions (PR 1.68; 1.64-1.72) and comorbid physical illness (PR 1.28; 1.23-1.32). We found no significant differences in risks for: all-cause mortality (HR 0.99; 0.91-1.09), natural death (HR 0.99; 0.90-1.09), unnatural death (HR 1.00; 0.59-1.72) or suicide (HR 1.68; 0.78-3.63). We did, however, observe a significantly elevated non-fatal self-harm risk: HR 1.83; 1.56-2.15., Conclusions: The absence of elevated premature mortality risk is reassuring. The raised prevalence of mental illness and increased non-fatal self-harm risk indicate a need for enhanced assessment and management of psychopathology associated with fatigue syndromes.