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Previous research suggests that up to 90% of individuals who die by suicide may have a mental disorder at the time of death but that levels of treatment may be low. This study aimed to examine undertreatment among patients with mental health conditions who died by suicide and to assess the association between patients' clinical and sociodemographic characteristics and treatment receipt.The study's sample included 12,909 patients in England and Wales who died by suicide within 12 months of contact with mental health services between 2001 and 2016. All patients had received a diagnosis of bipolar affective disorder, schizophrenia, depression, or an anxiety disorder. Records of patients who were not receiving treatment as recommended by national clinical guidelines at the time of death were examined for levels of nonprescription of treatment and nonadherence.Twenty-four percent of the patients did not receive treatment, 11% had not been prescribed treatment, and 13% were nonadherent with treatment. These proportions differed by diagnosis. After adjustment for main primary diagnosis, analyses showed that being under age 40, unemployment, living alone, drug misuse, medication side effects, and comorbid personality disorder were independently associated with a decreased likelihood of receiving treatment.One-quarter of patients with mental health conditions who die by suicide may not be receiving relevant interventions at the time of death. Levels of and reasons for nontreatment vary by diagnosis, but measures to address comorbid diagnoses and implement interventions to improve adherence in specific groups could have an impact.

In the UK there has been limited research examining temporal patterns of homicide. To our knowledge, no studies have linked patterns of homicide to the mental health characteristics of the perpetrator. The study examined a national consecutive case series of homicide offences committed between January 1996 and December 2015 in England. Clinical data were collected by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH). During this period 10,563 people committed a homicide. The offences were more likely to occur at the weekend, mostly on a Saturday. Weekend homicides were associated with: perpetrators under the age of 25, males and alcohol consumption. Homicides increased markedly on New Year’s Day, and public holidays. Those with a history of mental illness more commonly committed homicide during weekdays, suggesting a different pattern of offending. No change in pattern was found after licensing hours were extended in 2005 to allow 24-h licencing for the sale of alcohol. A public health approach should focus on educating young people on the health risks associated with alcohol, promoting responsible drinking and conflict avoidance, specifically on special events and at weekends.

Background There have been conflicting findings on temporal variation in suicide risk and few have examined the phenomenon in clinical populations. The study investigated seasonal and other temporal patterns using national data. Methods Data on 73,591 general population and 19,318 patient suicide deaths in England between 1997 and 2012 were collected through the National Confidential Inquiry into Suicide examining suicide rates in relation to month of the year, day of the week, and individual days of national or religious significance. Results Suicide incidence fell over successive months of the year and there was evidence of an overall spring peak. Monday was associated with the highest suicide rates and in the patient population this effect appeared to be more pronounced in those aged over 50 or those who lived alone. Suicide risk was significantly lower during Christmas, particularly for women. There was a peak in suicide on New Year's Day in the general population. Other ‘special days’ were not associated with a change in suicide incidence. Limitations We were limited to identifying associations between the variables investigated and were unable to explore causal mechanisms. We did not carry out comprehensive multi-variable adjustment in our regression models. Conclusions There is substantial seasonal and temporal variation in suicide deaths, and there appears to be some evidence in the clinical as well as the general population in England. Clinical services should be aware of the risk of suicide just after the weekend, especially in people who live alone, and the potential need for closer supervision during this period.

\ud Background\ud Risk assessment and management of suicidal patients is emphasized as a key component of care in specialist mental health services, but these issues are relatively unexplored in primary care services.\ud Aim\ud To examine risk assessment and management in primary and secondary care in a clinical sample of individuals who were in contact with mental health services and died by suicide.\ud Method\ud Data collection from clinical proformas, case records, and semi-structured face–to-face interviews with general practitioners. \ud Results\ud Primary and secondary care data was available for 198 of the 336 cases (59%). The overall agreement in the rating of risk between services was poor (overall kappa = 0.127; p = 0.10). Depression, care setting (post discharge), suicidal ideation at last contact and a history of self-harm were associated with a rating of higher risk. Suicide prevention policies were available in 25% of primary care practices and 33% of staff received training in suicide risk assessments.\ud Conclusion\ud Risk is difficult to predict, but the variation in risk assessment between professional groups may reflect poor communication. Further research is required to understand this. There appears to be a relative lack of suicide risk assessment training in primary care.

PURPOSE Self-harm is a public health problem that requires a better understanding of mortality risk. We undertook a study to examine premature mortality in a nationally representative cohort of primary care patients who had harmed themselves.\ud \ud METHODS During 2001–2013, a total of 385 general practices in England contributed data to the Clinical Practice Research Datalink with linkage to Office for National Statistics mortality records. We identified 30,017 persons aged 15 to 64 years with a recorded episode of self-harm. We estimated the relative risks of all-cause and cause-specific natural and unnatural mortality using a comparison cohort of 600,258 individuals matched on age, sex, and general practice.\ud \ud RESULTS We found an elevated risk of dying prematurely from any cause among the self-harm cohort, especially in the first year of follow-up (adjusted hazard ratio for that year, 3.6; 95% CI, 3.1–4.2). In particular, suicide risk was especially high during the first year (adjusted hazard ratio, 54.4; 95% CI, 34.3–86.3); although it declined sharply, it remained much higher than that in the comparison cohort. Large elevations of risk throughout the follow-up period were also observed for accidental, alcohol-related, and drug poisoning deaths. At 10 years of follow-up, cumulative incidence values were 6.5% (95% CI, 6.0%–7.1%) for all-cause mortality and 1.3% (95% CI, 1.2%–1.5%) for suicide.\ud \ud CONCLUSIONS Primary care patients who have harmed themselves are at greatly increased risk of dying prematurely by natural and unnatural causes, and especially within a year of a first episode. These individuals visit clinicians at a relatively high frequency, which presents a clear opportunity for preventive action. Primary care patients with myriad comorbidities, including self-harming behavior, mental disorder, addictions, and physical illnesses, will require concerted, multipronged, multidisciplinary collaborative care approaches.

BackgroundThe prevalence of mental illness is significantly higher among prisoners than among people in the wider community. Psychotropic prescribing in prisons is a complex and controversial area, where prescribers balance individual health needs against security and safety risks. However, there are no current data on prescribing patterns in prisons or how these compare with those in the wider community.AimsThe study aimed to determine the prevalence, appropriateness and acceptability of psychotropic prescribing in prisons. The objectives were to determine rates of prescribing for psychotropic medications, compared with those in the wider community; the appropriateness of psychotropic prescribing in prisons; and the perceived satisfaction and acceptability of prescribing decisions to patients and general practitioners (GPs).MethodEleven prisons, housing 6052 men and 785 women, participated in a cross-sectional survey of psychotropic prescribing. On census days, data were extracted from clinical records for all patients in receipt of hypnotics, anxiolytics, antipsychotics, antimanics, antidepressants and central nervous system stimulants. The Clinical Practice Research Datalink supplied an equivalent data set for a random sample of 30,602 patients prescribed psychotropic medicines in the community. To determine the acceptability of prescribing decisions, patients attending GP consultations at three prisons were surveyed (n = 156). Pre- and post-consultation questionnaires were administered, covering expectations and satisfaction with outcomes, including prescribing decisions. Doctors (n = 6) completed post-consultation questionnaires to explore their perspectives on consultations.ResultsOverall, 17% of men and 48% of women in prison were prescribed at least one psychotropic medicine. After adjusting for age differences, psychotropic prescribing rates were four times higher among men [prevalence ratio (PR) 4.02, 95% confidence interval (CI) 3.75 to 4.30] and six times higher among women (PR 5.95, 95% CI 5.36 to 6.61) than among community patients. There were significant preferences for certain antidepressant and antipsychotic drugs in prison, compared with in the community. In 65.3% of cases, indications for psychotropic drugs were recorded and upheld in theBritish National Formulary. Antipsychotic prescriptions were less likely than other psychotropics to be supported by a valid indication in the patient notes (PR 0.75, 95% CI 0.67 to 0.83). In the acceptability study, patients who identified mental health as their primary problem were more likely than individuals who identified other types of health problems to want to start, stop and/or change their medication (PR 1.46, 95% CI 1.23 to 1.74), and to report dissatisfaction following the consultation (PR 1.76, 95% CI 1.01 to 3.08). Doctors were more likely to issue prescriptions when they thought that the patient wanted a prescription (PR 4.2, 95% CI 2.41 to 7.28), they perceived pressure to prescribe (PR 1.66, 95% CI 1.26 to 2.19), and/or the problem related to mental health (PR 1.67, 95% CI 1.27 to 2.20).ConclusionsPsychotropic medicines were prescribed more frequently in prisons than in the community. Without current and robust data on comparative rates of mental illness, it is not possible to fully assess the appropriateness of psychotropic prescribing. Nonetheless, psychotropic medicines were prescribed for a wider range of clinical indications than currently recommended, with discernible differences in drug choice. Complex health and security concerns exist within prisons. Further research is necessary to determine the effect of psychotropic prescribing on physical health, and to determine the optimum balance between medicines and alternative treatments in prisons.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Web services technology is evolving as a base for implementing service-oriented architectures (SOA), which has become an important architectural style for Web applications development. As Web Services development has grown considerably, the need for Quality of Service (QoS) has become a substantial aspect for developing reliable service applications. In diverse business domains, Web services need to exhibit quality characteristics such as response time, availability, and reliability. However, a problem arises when a Web service is modified, updated or replaced by a new one. The new Web service may not fully match the QoS features provided from the previous one, this unavoidable problem is recognized as a mismatch. Mismatches can be found in different layers of the Web service interoperability stack and corresponding adapters are needed to deal with this issue. This paper proposes a study to investigate the feasibility of achieving interoperability in Web services by evaluating the functionality of adapters when mismatches appear at the policy layer, which includes non-functional properties like QoS.

BackgroundPersonality disorder (PD) is associated with elevated suicide risk, but the level of risk in primary care settings is unknown. We assessed whether PD among primary care patients is linked with a greater elevation in risk as compared with other psychiatric diagnoses, and whether the association is modified by gender, age, type of PD, and comorbid alcohol misuse.MethodsUsing data from the UK Clinical Practice Research Datalink, 2384 suicides were matched to 46,899 living controls by gender, age, and registered practice. Prevalence of PD, other mental disorders, and alcohol misuse was calculated for cases and controls separately and conditional logistic regression models were used to estimate exposure odds ratios. We also fitted gender interaction terms and formally tested their significance, and estimated gender age-specific effects.ResultsWe found a 20-fold increase in suicide risk for patients with PD versus no recorded psychiatric disorder, and a four-fold increase versus all other psychiatric illnesses combined. Borderline PD and PD with comorbid alcohol misuse were associated with a 37- and 45-fold increased risk, respectively, compared with those with no psychiatric disorders. Relative risks were higher for female than for male patients with PD. Significant risks associated with PD diagnosis were identified across all age ranges, although the greatest elevations were in the younger age ranges, 16–39 years.ConclusionsThe large elevation in suicide risk among patients diagnosed with PD and comorbid alcohol misuse is a particular concern. GPs have a potentially key role to play in intervening with patients diagnosed with PD, particularly in the presence of comorbid alcohol misuse, which may help reduce suicide risk. This would mean working with specialist care, agreed clinical pathways and availability of services for comorbidities such as alcohol misuse, as well as opportunities for GPs to develop specific clinical skills.

Objectives To investigate the impact of narrative verdicts on suicide statistics among 10–19-year-olds; to identify the number and rate of suicide and accidental deaths, particularly in 10–14-year-olds. Design National cohort study. Setting England and Wales. Methods Mid-year population estimates from the Office for National Statistics (ONS) were used to calculate rates per 100 000 population for suicide (undetermined and suicide verdicts) and accidental deaths (poisoning, hanging) for those aged 10–14 and 15–19. Trends in rates over time (2001–2010) were investigated using Poisson regression. Interaction tests were carried out to determine differences in trends between the two time periods (2001–2005 and 2006–2010). Results There were 1523 suicides (2.25/100 000). Suicide rates were highest in those aged 15–19 years (4.04/100 000) and in males (3.14/100 000). Between 2001 and 2010, rates significantly decreased among those aged 15–19 years (incidence rate-ratio (IRR): 0.95; 95% CI 0.93 to 0.97), with no change in rates of accidental deaths (IRR: 1.01, 95% CI 0.95 to 1.07). However, there was a significant interaction between the two time periods for accidental poisonings (2001–2005: IRR: 0.79 (95% CI 0.69 to 0.91); 2006–2010: IRR: 1.01 (95% CI 0.89 to 1.15), interaction p=0.012) and accidental hangings (2001–2005: IRR: 0.93 (95% CI 0.76 to 1.14); 2006–2010: IRR: 1.25 (95% CI 1.04 to 1.49), interaction=0.01) Undetermined deaths significantly decreased among females aged 15–19 yeras (IRR: 0.93; 95% CI 0.88 to 0.98). There were no significant trends among 10–14-year-olds. Conclusions Rates of suicide are higher among older adolescents and males. There was a significant fall in suicide rates in males aged 15–19 years that was not accounted for by changes in rates of accidental death. The absence of a significant trend in suicide or accidental deaths in those aged 10–14 years may have been the result of small numbers. However, monitoring should continue to identify longitudinal trends in all young people.

Background Mental illness is highly prevalent among prisoners. Although psychotropic medicines can ameliorate symptoms of mental illness, prescribers in prisons must balance clinical needs against risks to safety and security. Concerns have been raised at the large number of prisoners reportedly receiving psychotropic medicines in England. Nonetheless, unlike for the wider community, robust prescribing data are not routinely available for prisons. We investigated gender-specific patterns in the prevalence and appropriateness of psychotropic prescribing in English prisons. Methods We studied 6052 men and 785 women in 11 prisons throughout England. This represented 7.9 % of male and 20.5 % of female prisoners nationally. Using a cross-sectional design, demographic and prescription data were collected from clinical records of all prisoners prescribed psychotropic medicines, including hypnotic, anxiolytic, antipsychotic, anti-manic, antidepressant and Central Nervous System stimulant medications. Percentages and 95 % CIs were used to estimate the prevalence of prescribing. The Prescribing Appropriate Indicators tool was used to determine appropriateness. Prevalence Ratios (PR) were generated to make age-adjusted comparisons between prisoners and the general population using a dataset supplied by the Clinical Practice Research Datalink. Results Overall, 47.9 % (CI 44.4–51.4) of women and 16.9 % (CI 16.0–17.9) of men in prison were prescribed one or more psychotropic medicines. Compared with the general population, age-adjusted prescribing prevalence was six times higher among women (PR 5.95 CI 5.36–6.61) and four times higher among men (PR 4.02 CI 3.75–4.30). Undocumented or unapproved indications for prescriptions, not listed in the British National Formulary, were recorded in a third (34.7 %, CI 32.5–37.0) of cases, most commonly low mood and personality disorder. Conclusions Psychotropic medicines were prescribed frequently in prisons, especially among women, and for a wider range of indications than are currently recommended. These findings raise questions about whether the prescribing of psychotropic medicines in prisons is wholly appropriate and proportionate to the level of clinical need. Prisons need to develop a wider array of treatment responses, other than medicines, to effectively tackle mental illness, challenging behaviours and distress. Electronic supplementary material The online version of this article (doi:10.1186/s12888-016-1055-7) contains supplementary material, which is available to authorized users.

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. Background: Entering higher education is a time of transition that coincides with the typical age of onset of serious mental illness. Awareness of the distinguishing characteristics of students with mental illness who die by suicide may inform clinical management. Aim: We aimed to compare the characteristics of mental health patients who died by suicide as students with other young people who died by suicide. Method: UK data were analyzed for individuals aged 18–35 years in contact with mental health services who died by suicide from 1997 to 2012. Univariate analyses examined the sociodemographic, behavioral, and clinical features of those who died as students. Backward stepwise regression analysis identified factors independently associated with student deaths. Results: In all, 214 university students died by suicide within 12 months of mental health service contact. Factors associated with student deaths were: being younger, female, from an ethnic minority group, and a primary diagnosis of affective disorder. Medication nonadherence was less likely to be associated with student deaths. Conclusion: Deaths by suicide are split almost equally between male and female students, unlike the predominance of male suicide in the general population. There are clear differences in the characteristics of the student and nonstudent groups, although causation could not be established.

BACKGROUND: Patient suicide can be a devastating event for some general practitioners (GPs). Few guidelines exist to aid or support GPs in the aftermath of patient suicide.AIM: To explore GPs views on how they are affected by a patient suicide and the formal support available to them following a patient suicide.DESIGN: Questionnaires and semi-structured interviews.SETTING: General practices in the northwest of England.METHODS: About 198 semi-structured interviews were conducted as part of a retrospective study. Interviews were transcribed verbatim and analysed using descriptive statistics and a framework thematic approach.RESULTS: GPs were aged between 31 and 67 years, 144 (73%) were male and the number of years in practice varied between 8 and 40 years (median = 24 years). GPs were based at 133 (67%) urban and 65 (33%) rural practices, 30 (15%) were single-handed GP practices and 168 (85%) practices had two or more GPs. About 131 (66%) GPs reported being affected by patient suicide through feelings of grief, guilt and self-scrutiny. A greater number of years in practice may have been protective against these effects. About 54 (27%) GPs reported having mostly 'informal' support from peers or colleagues and support was less available to younger and single handed GPs.CONCLUSIONS: Our findings suggest that the majority of GPs are affected by patient suicide and most seek informal support from their peers and colleagues. Although many indicated that informal support systems were adequate and provided a protective environment, procedures should be developed to ensure the availability of guidelines for those who may require formal support.

Background Little is known about the clinical management of patients in primary care following self-harm. Methods A descriptive cohort study using data from 684 UK general practices that contributed to the Clinical Practice Research Datalink (CPRD) during 2001–2013. We identified 49,970 patients with a self-harm episode, 41,500 of whom had one complete year of follow-up. Results Among those with complete follow-up, 26,065 (62.8%, 62.3–63.3) were prescribed psychotropic medication and 6318 (15.2%, 14.9-15.6) were referred to mental health services; 4105 (9.9%, CI 9.6–10.2) were medicated without an antecedent psychiatric diagnosis or referral, and 4,506 (10.9%, CI 10.6–11.2) had a diagnosis but were not subsequently medicated or referred. Patients registered at practices in the most deprived localities were 27.1% (CI 21.5–32.2) less likely to be referred than those in the least deprived. Despite a specifically flagged NICE 'Do not do’ recommendation in 2011 against prescribing tricyclic antidepressants following self-harm because of their potentially lethal toxicity in overdose, 8.8% (CI 7.8-9.8) of individuals were issued a prescription in the subsequent year. The percentage prescribed Citalopram, an SSRI antidepressant with higher toxicity in overdose, fell sharply during 2012/2013 in the aftermath of a Medicines and Healthcare products Regulatory Agency (MHRA) safety alert issued in 2011. Conclusions A relatively small percentage of these vulnerable patients are referred to mental health services, and reduced likelihood of referral in more deprived localities reflects a marked health inequality. National clinical guidelines have not yet been effective in reducing rates of tricyclic antidepressant prescribing for this high-risk group., Highlights • The percentage of patients referred to mental health services is low. • Patients in the most deprived localities have the least chance of being referred. • One in ten are prescribed medication without a diagnosis or referral. • Eleven percent have a diagnosis but are not medicated or referred. • Despite guidance, a sizeable proportion were prescribed potentially toxic medication.

Homicide committed by multiple perpetrators is an understudied area and there has been no research investigating psychiatric differences between multiple and lone perpetrators of homicide. The objective of this study was to explore the demographic, criminological and psychiatric differences of the victims and perpetrators of multiple perpetrator homicides and compare them with the victims and perpetrators of lone perpetrator homicides. A 10-year (1997–2006) consecutive national sample of homicide perpetrators in England and Wales was used in this study. Of the 5806 homicides identified, 1485 were perpetrated by two or more convicted offenders. Convicted perpetrators who engaged in multiple perpetrator homicide were younger and single and less likely to be mentally ill at the time of the offence. It is concluded that supportive services should be provided for young people to reduce the rate of multiple perpetrator homicide.

Research into which aspects of service provision in mental health are most effective in preventing suicide is sparse. We examined the association between service changes, organisational factors, and suicide rates in a national sample.We did a before-and-after analysis of service delivery data and an ecological analysis of organisational characteristics, in relation to suicide rates, in providers of mental health care in England. We also investigated whether the effect of service changes varied according to markers of organisational functioning.Overall, 19 248 individuals who died by suicide within 12 months of contact with mental health services were included (1997-2012). Various service changes related to ward safety, improved community services, staff training, and implementation of policy and guidance were associated with a lower suicide rate after the introduction of these changes (incidence rate ratios ranged from 0·71 to 0·79, p0·0001). Some wider organisational factors, such as non-medical staff turnover (Spearman's r=0·34, p=0·01) and incident reporting (0·46, 0·0004), were also related to suicide rates but others, such as staff sickness (-0·12, 0·37) and patient satisfaction (-0·06, 0·64), were not. Service changes had more effect in organisations that had low rates of staff turnover but high rates of overall event reporting.Aspects of mental health service provision might have an effect on suicide rates in clinical populations but the wider organisational context in which service changes are made are likely to be important too. System-wide change implemented across the patient care pathway could be a key strategy for improving patient safety in mental health care.The Healthcare Quality Improvement Partnership commissions the Mental Health Clinical Outcome Review Programme, National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, on behalf of NHS England, NHS Wales, the Scottish Government Health and Social Care Directorate, the Northern Ireland Department of Health, Social Services and Public Safety, and the States of Jersey and Guernsey.

BackgroundThe rise in homicides by those with serious mental illness is of concern, although this increase may not be continuing.AimsTo examine rates of mental illness among homicide perpetrators.MethodA national consecutive case series of homicide perpetrators in England and Wales from 1997 to 2006. Rates of mental disorder were based on data from psychiatric reports, contact with psychiatric services, diminished responsibility verdict and hospital disposal.ResultsOf the 5884 homicides notified to the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness between 1997 and 2006, the number of homicide perpetrators with schizophrenia increased at a rate of 4% per year, those with psychotic symptoms at the time of the offence increased by 6% per year. The number of verdicts of diminished responsibility decreased but no change was found in the number of perpetrators receiving a hospital order disposal. The likeliest explanation for the rise in homicide by people with psychosis is the misuse of drugs and/or alcohol, which our data show increased at a similar magnitude to homicides by those with psychotic symptoms. However, we are unable to demonstrate a causal association. Although the Poisson regression provides evidence of an upward trend in homicide by people with serious mental illness between 1997 and 2006, the number of homicides fell in the final 2 years of data collection, so these findings should be treated with caution.ConclusionsThere appears to be a concomitant increase in drug misuse over the period, which may account for this rise in homicide. However, an increase in the number of people in contact with mental health services may suggest that access to mental health services is improving. Previous studies have used court verdicts such as diminished responsibility as a proxy measure of mental disorder. Our data indicate that this does not reflect accurately the prevalence of mental disorder in this population.

Objectives To describe attendance at emergency departments (EDs) in the year prior to suicide for a sample of mental health patients. To examine the characteristics of those who attended (particularly those who attended frequently) prior to suicide. Design Case review of ED records for 286 individuals who died within 12 months of mental health contact in North West England (2003e2005). Method Cases identified through the National Confidential Inquiry into Suicide were checked against regional EDs to establish attendance in the year prior to death. Records were examined to establish the number of attendances, reason for the final, non-fatal attendance, treatment offered and outcome. Results One hundred and twenty-four (43%) individuals had attended the ED at least once in the year prior to their death, and of these, 35 (28%) had attended the ED on more than three occasions. These frequent attenders died by suicide significantly sooner after their final, nonfatal attendance than other attenders. A clinical history of alcohol misuse was also associated with early death following ED attendance. Conclusions Over 40% of our clinical sample attended an ED in the year prior to death, and some individuals attended particularly frequently. EDs may therefore represent an important additional setting for suicide prevention in mental health patients. The majority of attendances prior to suicide were for self-harm or to request psychiatric help. Clinicians should be alert to the risk associated with such presentations and to the possible association between frequent attendance and suicide.

This study aimed to describe the social, behavioural and offence characteristics of all convicted perpetrators of homicide aged 17 and under; to examine their previous contact with mental health services, and to discuss strategies for homicide prevention. An eight-year (1996-2004) sample of 363 juvenile homicide perpetrators in England and Wales was examined. The majority of perpetrators were male, used a sharp instrument, and most victims were acquaintances or strangers. Over half had previously offended. A history of alcohol and/or drug misuse was common, as was the prevalence of family dysfunction, abuse, educational difficulties or discipline problems. Previous contact with mental health services was rare. Earlier intervention targeting social and psychological adversity and substance misuse could help to reduce the level of risk for future violence, and may reduce homicide rates among juveniles. Strengthening engagement with young offenders and increasing resources to prevent recidivism may also be beneficial.

Comparisons of psychiatric patients who die by suicide using different methods are scarce. We aimed to establish the methods of suicide used by those who are currently or have recently been in contact with mental health services in England and Wales (N = 6,203), and describe the social and clinical characteristics of suicides by different methods. We found that hanging, self-poisoning, and jumping (from a height or in front of a moving vehicle) were the most common methods of suicide, accounting for 79% of all deaths. The implications of these and other findings are discussed.

Background: Psychiatric reports can be prepared in homicide cases, pretrial, to determine the mental state of the offender at the time of the offence and to make recommendations to the court. Objective: To explore the recommendations and agreement between authors in the psychiatric court reports of homicide offenders and to establish the affect these have on court outcome. Method: Analysis of a five-year (1996–2001) consecutive national sample of homicide perpetrators in England and Wales. Results: The agreement between prosecution and defence report writers regarding diagnosis was moderate (56%, κ = .49), but rose to very good levels between authors for the same party (prosecution: 89%, κ = .87; defence: 95%, κ = .94). Report writers for the defence were more likely to diagnose a mental illness at the time of the offence (127 cases, 50% v. 136 cases, 28%) and to state that the perpetrator had an ‘impairment of responsibility’ (36 cases, 28% v. 23 cases, 17%). Conclusions: There is at best a moderate agre...

Background: Approximately 30 incidents of homicide followed by suicide occur in England and Wales each year. Previous studies have not examined mental health characteristics in any detail. Aims: This study aims to identify the social, clinical, and criminological characteristics of a national sample of perpetrators, to identify any previous contact with mental health services and to establish risk of suicide after homicide. Method: A national cross-sectional study of perpetrators in England and Wales 1996–2005. Results: 203 incidents were recorded over 9 years. The median age of perpetrators was 41 years (range 18–88 years); most were male. Men more often killed a spouse/partner, whilst women more commonly killed their children. Eighty-four (42%) perpetrators died by suicide on the day of the homicide. The most common method of homicide was sharp instrument (44, 23%). Fifty-nine (29%) used hanging as a method of suicide. Twenty (10%) had previous contact with mental health services, 14 were seen within a ...

Background: Suicide is a leading cause of death among youths. Comparatively few studies have studied recent trends over time, or examined rates and characteristics of service contact in well-defined national samples. Methods: Data on general population suicides and mid-year population estimates were used to calculate suicide rates (per 100,000/year) among youths aged 10-19 years in the United Kingdom. We then determined the proportion of youths who had been in mental health service contact in the year prior to death. Social and clinical data were collected via questionnaires sent to clinicians who had provided care. Results: The general population rate of suicide was higher in males than females, and was higher in 15-19-year-olds compared to 10-14-year-olds. Suicide rates for 10-19-year-olds declined by 28% between 1 January 1997 and 31 December 2003 (compared with an 8% reduction in those aged>19 years); the fall was particularly marked for males. Mental health service contact was low at 14% (compared with 26% for adults), especially for males (12%). Youths in mental health contact were characterised by: diagnosis of affective disorder, mental illness history, residential instability, self-harm, and substance misuse. Over half of youths were living with parents and one-fifth were in full-time education. Conclusions: The suicide rate for 10-19-year-olds in the UK appeared to fall between 1997 and 2003. Further monitoring of suicide rates is needed to determine whether this trend has continued for the most recent years (e.g., 2004-7). The fall in rates may have been related to socio-economic or clinical factors. The rate of contact with services was low compared to adults, particularly in males. This is concerning because young males have the highest suicide rate in the UK. Suicide prevention in young people is likely to require a multi-agency approach. Language: en

Summary Background The media attention received by homicides committed by patients with mental illness is thought to increase stigma. However, people with mental illness can also be victims of violence. We aimed to assess how often victims of homicide are current mental health patients and their relationship to the perpetrators. Methods In a national consecutive case-series study, we obtained data for victims and perpetrators of all confirmed homicides between Jan 1, 2003, and Dec 31, 2005, in England and Wales. We requested information about contact with mental health services in the 12 months before the homicide for all victims and perpetrators. For victims and perpetrators who had contact with mental health services in the 12 months before homicide, we sent questionnaires to the clinician responsible for the patient's care. Findings 1496 victims of confirmed homicide died between Jan 1, 2003, and Dec 31, 2005, in England and Wales. Patients with mental illness were more likely to die by homicide than were people in the general population (incidence rate ratio 2·6, 95% CI 1·9–3·4). 90 homicide victims (6%) had contact with mental health services in the 12 months before their death. 213 patients with mental illness were convicted of homicide in the same 3 year period. 29 of 90 patient victims were killed by another patient with mental illness. In 23 of these 29 cases, the victim and perpetrator were known to each other, and in 21 of these cases, the victims and perpetrators were undergoing treatment at the same National Health Service Trust. In these 29 cases in which patient victims were killed by another patient with mental illness, alcohol and drug misuse (19 victims [66%], 27 perpetrators [93%]) and previous violence (7 victims [24%], 7 perpetrators [24%]) were common in both victims and, particularly, perpetrators. In seven of the 29 cases in which the victim was killed by another patient with mental illness, both victim and perpetrator were diagnosed with schizophrenia. Interpretation The high risk of patients with mental illness being victims of homicide is an important antistigma message, although this risk partly comes from other patients with mental illness; overall, the risk of patients committing homicide is greater than the risk of being a victim of homicide. Identification and safeguarding of patients at risk of violence should be prominent in clinical risk assessment. Funding Healthcare Quality Improvement Partnership.

This preliminary analysis is part of the baseline phase of a longitudinal study designed to investigate the professional development of primary and secondary teachers across England. The study addresses four key research areas. The prevailing models of professional development for teachers in England are identified in this baseline phase and the scene is set for the remaining areas of investigation to be addressed (annual data collection sweeps will continue).

Although initially focusing on the parental diagnosis of cancer, the findings reported in this paper have a much wider significance for pastoral care. Earlier research suggested that parental disclosure of diagnosis was not handled sensitively by some secondary schools. The earlier research dealt with the responses of parents and pupils, whilst this research focuses on the perceptions of head teachers. Using unstructured interviews, three key areas were investigated: the recommended procedures for parental contact with the school in relation to confidential issues; the policies or procedures which help or constrain staff from helping distressed children on an individual basis; the needs and concerns of headteachers and staff related to pastoral care in schools. The data provide important insights into the perceptions and issues concerning pastoral care in the current climate.

This study investigated the psychosocial adjustment of 80 school-age children (aged 8 to 16 years) during the first year of a parent's cancer diagnosis. Based on a cognitive model of stress and coping, the aims were to consider within-group variability in children's responses and to identify the strongest factors associated with good or poor adjustment. Mixed methods of data collection (standardized measures and semistructured interviews) were used to facilitate a more sensitive and reliable assessment of the children's experiences. The study was innovative in triangulating the sources of outcome measures and thus obtained self-reported data as well as assessments from parents and teachers. After multivariate analysis, the two main risk factors shown to be independently associated with poor adjustment in children were low self-esteem (p = .002) and poor adjustment in the parent with cancer (p = .01).

BACKGROUND: People with bipolar disorder may be at increased risk of suicidal behaviour but there are few prospective studies of self-harm in this group. Our aim was to describe the characteristics and outcome (in terms of repetition) for individuals with bipolar disorder who presented to hospital following self-harm. METHOD: A nested case-control study was carried out using a large prospective self-harm database (1997-2010) in Manchester, UK. Characteristics of bipolar cases and non-bipolar controls were compared using conditional logistic regression, and outcomes were assessed via survival analyses. RESULTS: Bipolar cases (n=103) were more likely to repeat self-harm than controls (n=515): proportion with at least one repeat episode 58% vs. 25%, HR 3.08 (95% CI; 2.2-4.18). Previous self-harm, unemployment, contact with psychiatric services and sleep disturbance were all more common in cases than controls. Even after adjustment for known risk factors, the risk of repetition remained higher in the bipolar group (adjusted HR 1.68; 95% CI; 1.10-2.56). LIMITATIONS: The study covers cases from hospital sites in Manchester, UK, and therefore only includes self-harm that was serious enough to present at hospital emergency departments. CONCLUSION: People with bipolar disorder who self-harm have a higher risk of repetition than people who self-harm more generally. Adjusting for some known risk factors moderated, but did not abolish, this finding. Other factors, such as impulsivity, may also be important.

This paper reports the findings of new research on the school as a source of psychosocial support for primary‐ and secondary‐stage children of cancer patients. It begins with a restatement of the importance of pastoral care in schools and of teachers listening to children. Academic success is an important factor in maintaining positive self‐esteem and psychological functioning. The authors show how parents’ cancer affected their children at schoool; how children do not disclose important personal and familial information; and that this can mean that problems in school are not fully understood nor supported. Peers had an important role to play in adjustment.

Web services technology is evolving as a base for implementing service-oriented architectures (SOA), which has become an important architectural style for Web applications development. As Web Services development has grown considerably, the need for Quality of Service (QoS) has become a substantial aspect for developing a reliable service applications. In diverse business domains, Web services need to exhibit quality characteristics such as response time, availability, and reliability. However, a problem arises when a Web service is modified, updated or replaced by a new one. The new Web service may not fully match the QoS features provided from the previous one, this unavoidable problem is recognized as a mismatch. Mismatches are found in different layers of the Web service interoperability stack and corresponding adapters are needed to deal with this issue. This paper proposes a study to investigate the feasibility of achieving interoperability in Web services by evaluating the functionality of adapters when mismatches appear at the policy layer, which includes non-functional properties like QoS.

The study reported in this paper was undertaken to discover the extent of pastoral care training carried out during secondary initial teacher education. Questionnaires were sent to heads of initial teacher education institutions in England and Wales. It was found that institutions were likely to provide some form of training in pastoral care but the extent and method of training varied greatly between institutions. However, training in actual practical skills such as basic counselling skills was much less likely to be available. The authors conclude that there is still some considerable way to go before newly qualified teachers are likely to feel adequately prepared for their pastoral roles.

Meeting the educational needs of students currently requires moving toward collaborative electronic and mobile learning systems that parallel the vision of Web 2.0. However, factors such as data freedom, brokerage, interconnectivity and the Internet of Things add to a vision for Web 3.0 that will require con- sideration in the development of future campus-based, distance and vocational study. So, education can, in future, be expected to require deeper technological connections between students and learning environments, based on significant use of sensors, mobile devices, cloud computing and rich-media visualization. Therefore, we discuss challenges associated with such a futuristic campus con- text, including how learning materials and environments may be enriched by it. As an additional novel element the potential for much of that enrichment to be realized through development by students, within the curriculum, is also considered. We will conclude that much of the technology required to embrace the vision of Web 3.0 in education already exists, but that further research in key areas is required for the concept to achieve its full potential.

The study investigated the psychological adjustment of 99 siblings of children with cancer. At 6 months post-diagnosis, 24 siblings had scores in the borderline or clinical range on parent- and teacher-completed measures of behavioural adjustment and were reported to have shown negative changes in behaviour since diagnosis. The results of logistic regression analysis indicated that problems in adjustment were related to the degree of disruption of family life occasioned by the illness, the resources available to the family to cope with the effects of such disruption on siblings and siblings' perceptions of negative interpersonal effects on their lives.

Data were collected from 1024 teachers from secondary schools throughout England and Wales. The sample included teachers of all National Curriculum subjects, and analysis revealed that cancer was most often taught about in science or personal and social education (PSE). There was a significant association between the teachers’ knowledge of cancer and their involvement in cancer education. Teachers who showed a greater awareness of cancer issues are more likely to have taught about cancer than their less knowledgeable colleagues. Data are also available on why some teachers had not taught about cancer. It appeared that the teachers’ lack of knowledge and the poor supply of educational resources were primary factors. The authors conclude that these issues must be addressed if there is to be an increase in cancer education. This can only occur within the broader context of training and support for general school health education.

In our exciting world of pervasive computing and always-available mobile internet, meeting the educational needs of students has seen a growing trend toward collaborative electronic and mobile learning systems that build on the vision of Web 2.0. However, other trends relevant to modern students must not be ignored, including data freedom, brokerage and interconnectivity. Such factors are associated with the Internet of Things and the vision for Web 3.0, and so include the needs for greater consideration of data context and educational personalization so important to the future of campus-based, distance and vocational study. Therefore, future education can be expected to require a deeper technological connection between students and learning environments, in a manner requiring significant use of sensors, mobile devices, cloud computing and rich-media visualization. This paper considers the challenges associated with adopting such a futuristic concept as a means of enriching learning materials and environments within a university context. It will be concluded that much of the technology required to embrace the vision of Web 3.0 in education already exists, but that further research in key areas is required for the concept to achieve its full potential.

The purpose of this study was to identify the policies, if any, regulating where and when smoking was allowed in educational establishments for students aged 16 and over, and to relate them to smoking prevalence. The methods used were postal questionnaires to all directors of local education authorities in England and Wales and to a sample of school and college principals in 1990. Self-administered questionnaires were used for the sample of students, supervised by staff. The results showed that 37 per cent of the responding local directors of education had a written policy on smoking for the schools and colleges in their area. Responses from principals showed that 83 per cent of colleges and 14 per cent of schools officially allowed students aged 16 and over to smoke. Eighty-three per cent of colleges and 97 per cent of schools allowed staff to smoke, but not usually in front of students. Policy and prevalence were strongly related in colleges, but not in the schools. The possible reasons for and implications of these findings are discussed. Overall, smoking students smoked fewer cigarettes (7 per week during attendance hours and 18 outside) in establishments where they were not allowed to smoke, as against 17 during attendance hours and 28 outside when the policy allowed smoking. The policy was still significantly related to lower smoking prevalence in colleges when other factors were taken into account. The response rates were low and the risk of bias is high, however; the findings suggest the need to investigate the topic further.

Background: Socioculturally meaningful events have been shown to influence the timing of suicide, but the influence of psychiatric disorder on these associations has seldom been studied. Aims: To investigate the association between birthday and increased risk of suicide in the general population and in a national sample of psychiatric patients. Methods: Data on general population suicides and suicide by individuals in recent care of mental health services were examined for day of death in relation to one’s birthday using Poisson regression analysis. Results: An increased risk of suicide was observed on day of one’s birthday itself for males in both the general population (IRR = 1.39, 95% CI = 1.18–1.64, p < .01) and the clinical population (IRR = 1.48, 95% CI = 1.07–2.07, p = .03), especially for those aged 35 years and older. In the clinical population, risk was restricted to male patients aged 35–54 and risk extended to the 3 days prior to one’s birthday. Conclusions: Birthdays are periods of increased risk for men aged 35 and older in the general population and in those receiving mental health care. Raising health-care professionals’ awareness of patient groups at greater risk at this personally significant time may benefit care planning and could facilitate suicide prevention in these individuals.

Clinical characteristics and risk factors associated with sudden unexplained death (SUD) in the psychiatric population are unclear. Psychiatric in-patients (England, Wales) who met criteria for SUD were identified (1 March 1999–31 December 2005). Cases were matched with controls (in-patients alive on the day a SUD occurred). Data were collected via questionnaires. Some 283 cases of SUD were identified (41 annually), with a rate of 2.33/10,000 mental health admissions (in England). Electrocardiograms were not routine, cardiopulmonary resuscitation equipment was sometimes unavailable, attempts to resuscitate patients were carried out on one-half of all patients and post mortems/inquiries were not routine. Restraint and seclusion were uncommon. Risk factors included: benzodiazepines (odds ratio (OR): 1.83); ≥2 antipsychotics (OR: 2.35); promazine (OR: 4.02); diazepam (OR: 1.71); clozapine (OR: 2.10); cardiovascular disease (OR: 2.00); respiratory disease (OR: 1.98); diagnosis of dementia (OR: 2.08). Venlafaxine and a diagnosis of affective disorder were associated with reduced ORs (OR: 0.42; OR: 0.65). SUD is relatively rare, although it is more common in older patients and males. Prevention measures may include safer prescribing of antipsychotics and improved physical health care. The contribution of restraint or seclusion to SUD in individual cases is unclear. A uniform definition of SUD may help to identify contributing factors.

In England and Wales, a lifetime history of mental disorder is recorded in almost a third of homicides but mental illness as a defence in homicide cases has recently come under review. In this study, we aimed to compare the social, criminological and clinical characteristics of women and men convicted of homicide and secondly, to understand how pathways through the judicial system differ by gender of the perpetrator, characteristics of the offence and mental illness. A cross sectional study of 4572 convicted homicide perpetrators in England and Wales 1997-2004 was performed. Significantly more women who had committed homicide had a lifetime history of mental illness and were more likely to be mentally ill at the time of offence compared to men. Women more often received non-custodial sentences, whether or not they had mental illness. If the victim were a child or other relative, the courts were more lenient with women. Gender and the presence of mental illness both influence the characteristics of homicide and outcome of the legal process in the UK. Our findings suggest that all perpetrators of homicide should have a psychiatric assessment pre-trial. Psychiatrists need to rate risk objectively in a gender blind way when providing psychiatric reports to be used as evidence in court. © 2010.

Background Primary care may be a key setting for suicide prevention. However, comparatively little is known about the services available in primary care for suicide prevention. The aims of the current study were to describe services available in general practices for the management of suicidal patients and to examine GPs views on these services. We carried out a questionnaire and interview study in the North West of England. We collected data on GPs views of suicide prevention generally as well as local mental health service provision. Findings During the study period (2003-2005) we used the National Confidential Inquiry Suicide database to identify 286 general practitioners (GPs) who had registered patients who had died by suicide. Data were collected from GPs and practice managers in 167 practices. Responses suggested that there was greater availability of services and training for general mental health issues than for suicide prevention specifically. The three key themes which emerged from GP interviews were: barriers accessing primary or secondary mental health services; obstacles faced when referring a patient to mental health services; managing change within mental health care services Conclusions Health professionals have an important role to play in preventing suicide. However, GPs expressed concerns about the quality of primary care mental health service provision and difficulties with access to secondary mental health services. Addressing these issues could facilitate future suicide prevention in primary care.

AS part of a larger survey on children, smoking and advertising, 7,047 children aged 11-16 years were invited (a) to describe their favourite advertisement and (b) to explain why they chose it. The aim of this part of the study was to assess the popularity of advertisements for beers and lagers in the context of children's appreciation of advertisements for a wide variety of consumer products. The results high lighted the popularity of television advertisements, and particularly those which used humour to market the product. Beer and lager products were overall the most popular choice of a 'favourite' advert for 22 per cent of all boys and 9 per cent of all girls. For young males, the popularity of beer and lager advertise ments increased significantly between the ages of 11-16 years (p

THE results described in this paper are part of a wider survey of children and advertising. These results obtained in 1990, show that 35 per cent of a sample of 7047 children aged 11-16 years, reported they had seen cigarette advertisements on television. Although cigarette advertisements had in fact been seen in films, soaps and sponsored sports programmes, the majority of the children thought they had seen them in television commercial breaks ('adverts'). General awareness of cigarette advertisements in commercial breaks decreased significantly from 11 to 16 years, but increased significantly from 11 to 16 years in association with sports programmes. Non-smokers were significantly more likely than smokers to report seeing cigarette advertisements in commercial breaks, but children who smoked were more aware of advertisements in sports programmes and television soaps. There were clear differences between the brand names recalled in association with sports programmes and those seen in the other television programmes.

Previous studies have reported differing rates of consultation with GPs prior to suicide. Patients with a psychiatric history have higher rates of consultation and consult closer to the time of their death.To investigate the frequency and nature of general practice consultations in the year before suicide for patients in current, or recent, contact with secondary mental health services.Retrospective case-note study and semi-structured interviews.General practices in the northwest of England.General practice data were obtained by a retrospective review of medical records (n = 247) and semi-structured interviews with GPs (n = 159).GP records were reviewed in 247 of the 286 cases (86%). Overall, 91% of individuals (n = 224) consulted their GP on at least one occasion in the year before death. The median number of consultations was 7 (interquartile range = 3-10). Interviews were carried out with GPs with regard to 159 patients. GPs reported concerns about their patient's safety in 43 (27%) cases, but only 16% of them thought that the suicide could have been prevented. Agreement between GPs and mental health teams regarding risk of suicide was poor. Both sets of clinicians rated moderate to high levels of risk in only 3% of cases for whom information was available (n = 139) (overall kappa = 0.024).Consultation prior to suicide is common but suicide prevention in primary care is challenging. Possible strategies might include examining the potential benefits of risk assessment and collaborative working between primary and secondary care.

OBJECTIVES: Wood dust data held in the Health and Safety Executive (HSE) National Exposure DataBase (NEDB) were reviewed to investigate the long-term changes in inhalation exposure from 1985 to 2005. In addition, follow-up sampling measurements were obtained from selected companies where exposure measurements had been collected prior to 1994, thereby providing a follow-up period of at least 10 years, to determine whether changes in exposure levels had occurred, with key staff being interviewed to identify factors that might be responsible for any changes observed. METHODS: Analysis of the temporal trend in exposure concentrations was performed using Linear Mixed Effect Models on the log-transformed NEDB data set and expressed as the relative annual change in concentration. RESULTS: For the NEDB wood dust data, an annual decline of geometric mean (GM) exposure of 8.1% per year was found based on 1459 exposure measurements collected between 1985 and 2003. This trend was predominantly observed in data from inspection visits (measurements collected on a mandatory basis by a Specialist HSE Inspector) (n = 1009), while data from representative surveys (measurements collected on a voluntary basis to provide information on current practices and exposures) remained relatively stable. Ten follow-up surveys in individual workplaces in 2004-2005 resulted in 70 new measurements and for each of the companies resurveyed, the GM of the wood dust exposure decreased between sampling surveys. CONCLUSION: Analysis of the temporal trend in UK wood dust exposure concentrations revealed declines of 8% per annum. Interviews with key long-serving employees and management suggest that factors such as technological changes in production processes, response to new legislation, and enforcement agency inspections, together with global economic trends, could be linked to the downward trends observed.