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Background Self-harm in pregnancy or the year after birth (‘perinatal self-harm’) is clinically important, yet prevalence rates, temporal trends and risk factors are unclear. Methods A cohort study of 679 881 mothers (1 172 191 pregnancies) was conducted using Danish population register data-linkage. Hospital treatment for self-harm during pregnancy and the postnatal period (12 months after live delivery) were primary outcomes. Prevalence rates 1997–2015, in women with and without psychiatric history, were calculated. Cox regression was used to identify risk factors. Results Prevalence rates of self-harm were, in pregnancy, 32.2 (95% CI 28.9–35.4)/100 000 deliveries and, postnatally, 63.3 (95% CI 58.8–67.9)/100 000 deliveries. Prevalence rates of perinatal self-harm in women without a psychiatric history remained stable but declined among women with a psychiatric history. Risk factors for perinatal self-harm: younger age, non-Danish birth, prior self-harm, psychiatric history and parental psychiatric history. Additional risk factors for postnatal self-harm: multiparity and preterm birth. Of psychiatric conditions, personality disorder was most strongly associated with pregnancy self-harm (aHR 3.15, 95% CI 1.68–5.89); psychosis was most strongly associated with postnatal self-harm (aHR 6.36, 95% CI 4.30–9.41). For psychiatric disorders, aHRs were higher postnatally, particularly for psychotic and mood disorders. Conclusions Perinatal self-harm is more common in women with pre-existing psychiatric history and declined between 1997 and 2015, although not among women without pre-existing history. Our results suggest it may be a consequence of adversity and psychopathology, so preventative intervention research should consider both social and psychological determinants among women with and without psychiatric history.

BackgroundThe excess mortality following first-contact psychosis is well recognized. However, the causes of death in a complete incidence cohort and mortality patterns over time compared with the general population are unknown.MethodAll 2723 patients who presented for the first time with psychosis in three defined catchment areas of the UK in London (1965–2004, n=2056), Nottingham (1997–1999, n=203) and Dumfries and Galloway (1979–1998, n=464) were traced after a mean of 11.5 years follow-up and death certificates were obtained. Data analysis was by indirect standardization.ResultsThe overall standardized mortality ratio (SMR) for first-contact psychosis was 184 [95% confidence interval (CI) 167–202]. Most deaths (84.2%, 374/444) were from natural causes, although suicide had the highest SMR (1165, 95% CI 873–1524). Diseases of the respiratory system and infectious diseases had the highest SMR of the natural causes of death (232, 95% CI 183–291). The risk of death from diseases of the circulatory system was also elevated compared with the general population (SMR 139, 95% CI 117–164) whereas there was no such difference for neoplasms (SMR 111, 95% CI 86–141). There was strong evidence that the mortality gap compared with the general population for all causes of death (pp=0.01) increased over the four decades of the study. There was weak evidence that cardiovascular deaths may be increasing relative to the general population (p=0.07).ConclusionsPeople with first-contact psychosis have an overall mortality risk that is nearly double that of the general population. Most excess deaths are from natural causes. The widening of the mortality gap over the last four decades should be of concern to all clinicians involved in delivering healthcare.

In the past 40 years, the proportion of women selected for medical school in the UK has risen from just 20% to approximately 60-65%, 1 reflecting the determination, ambition and ability of young women. This has been accompanied by increasing numbers of women selecting a career in psychiatry. However, in the higher echelons of academic psychiatry, as with other branches of academic medicine, women are under-represented. Within academic psychiatry, just 13% of clinical professors are women compared with 29% of clinical lecturers. 2 Women make up 35% of the Academic Psychiatry Faculty of the Royal College of Psychiatrists, comprising 40% of research fellows but only 10% of professors. At the Academy of Medical Sciences, 55 fellows have an interest in psychiatry, of whom 9 are female (16%), whereas the British Academy has 34 fellows in psychology, 10 of whom are female (29%). In wider academic medicine in the UK the situation is no better. Despite an increase in the proportion of women in medical schools, both as students and staff, women remain under-represented compared with their male counterparts at senior levels. The Medical Schools Council report that the number of women in clinical academia decreases at each grade of the academic career ladder; only 11% of clinical professorial staff in medicine are women, compared with 36% of clinical lecturers. 2 Furthermore, the Council recently reported that six medical schools across all specialties reported no female clinical professors in post in the last round of data collection. On the other hand, according to the Professional Standards Department at the Royal College of Psychiatrists, of the 22 postgraduate deanery schools, 7 have female heads of psychiatry (32%) and the Lead Dean is a woman (Professor Jacky Hayden). In the USA, similar statistics emerge for percentages of senior academic female psychiatrists: in 2002, women made up 37% of faculty in departments of psychiatry, with 29% of associate professors and 15% of full professors being women. Only eight women had chaired a medical school psychiatry department and no female psychiatrist had been dean of a medical school in the USA. 3

Background. The high risk of suicide in bipolar disorder is well recognized, but may have been overestimated. There is conflicting evidence about deaths from other causes and little known about risk factors for suicide. We aimed to estimate suicide and mortality rates in a cohort of bipolar patients and to identify risk factors for suicide.Method. All patients who presented for the first time with a DSM-IV diagnosis of bipolar I disorder in a defined area of southeast London over a 35-year period (1965–1999) were identified. Mortality rates were compared with those of the 1991 England and Wales population, indirectly standardized for age and gender. Univariate and multivariate analyses were used to test potential risk factors for suicide.Results. Of the 239 patients in the cohort, 235 (98·3%) were traced. Forty-two died during the 4422 person-years of follow-up, eight from suicide. The standardized mortality ratio (SMR) for suicide was 9·77 [95% confidence interval (CI) 4·22–19·24], which, although significantly elevated compared to the general population, represented a lower case fatality than expected from previous literature. Deaths from all other causes were not excessive for the age groups studied in this cohort. Alcohol abuse [hazard ratio (HR) 6·81, 95% CI 1·69–27·36, p=0·007] and deterioration from pre-morbid level of functioning up to a year after onset (HR 5·20, 95% CI 1·24–21·89, p=0·024) were associated with increased risk of suicide.Conclusions. Suicide is significantly increased in unselected bipolar patients but actual case fatality is not as high as previously claimed. A history of alcohol abuse and deterioration in function predict suicide in bipolar disorder.