The number of people presenting to hospital emergency departments after self-harming has increased in England. However, most people who self-harm do not present to hospitals, so whether this rise ...reflects an increase in the prevalence of self-harm in the community is unknown. Also unknown is whether the prevalence of non-suicidal self-harm (NSSH) or suicidal self-harm, or both, has increased. We aimed to establish temporal trends in the prevalence of NSSH in England.
We analysed data from participants in the 2000 (n=7243), 2007 (n=6444), and 2014 (n=6477) Adult Psychiatric Morbidity Surveys of the general population, selecting those aged 16–74 years and living in England. We used weighted data and controlled for complex survey design. We generated temporal trends in lifetime prevalence and methods of, and motivations for, NSSH, and consequent service contact. We used multiple variable logistic regression analyses to investigate factors associated with service contact.
The prevalence of self-reported lifetime NSSH increased from 2·4% (95% CI 2·0–2·8) in 2000, to 6·4% (5·8–7·2) in 2014. Increases in prevalence were noted in both sexes and across age groups—most notably in women and girls aged 16–24 years, in whom prevalence increased from 6·5% (4·2–10·0) in 2000, to 19·7% (15·7–24·5) in 2014. The proportion of the population reporting NSSH to relieve unpleasant feelings of anger, tension, anxiety, or depression increased from 1·4% (95% CI 1·0–2·0) to 4·0% (3·2–5·0) in men and boys, and from 2·1% (1·6–2·7) to 6·8% (6·0–7·8) in women and girls, between 2000 and 2014. In 2014, 59·4% (95% CI 54·7–63·9) of participants who had engaged in NSSH reported no consequent medical or psychological service contact, compared with 51·2% (42·2–60·0) in 2000 and 51·8% (47·3–56·4) in 2007. Male participants and those aged 16–34 years were less likely to have contact with health services than were female participants and older people.
The prevalence of NSSH has increased in England, but resultant service contact remains low. In 2014, about one in five female 16–24-year-olds reported NSSH. There are potential lifelong implications of NSSH, such as an increased frequency of suicide, especially if the behaviours are adopted as a long-term coping strategy. Self-harm needs to be discussed with young people without normalising it. Young people should be offered help by primary care, educational, and other services to find safer ways to deal with emotional stress.
NHS Digital, English Department of Health and Social Care, and the National Institute for Health Research.
Suicide in pregnant and postnatal women is an important cause of maternal death, but evidence to guide suicide prevention in this group is scarce. We aimed to compare the trend, nature, and ...correlates of suicide in perinatal and non-perinatal women in contact with psychiatric services.
We used 1997-2012 data from the UK National Confidential Inquiry into Suicides and Homicides by People with Mental Illness, which includes all suicides by people (age ≥10 years) who had been in contact with psychiatric services in the previous year. The study sample comprised all women who died by suicide in pregnancy or the first postnatal year (perinatal suicides), and all women in the same age range who died by suicide outside this period (non-perinatal suicides). We compared suicides among perinatal and non-perinatal women with logistic regression of multiply imputed data.
The study sample included 4785 women aged 16-50 years who died by suicide, of whom 98 (2%) died in the perinatal period. Of the 1485 women aged 20-35 years, 74 (4%) women died in the perinatal period. Over the course of the study, we recorded a modest downward trend in the mean number of women dying by suicide in the non-perinatal period (-2·07 per year SD 0·96; p=0·026), but not the perinatal period (-0·07 per year 0·37; p=0·58). Compared with non-perinatal women, women who died by suicide in the perinatal period were more likely to have a diagnosis of depression (adjusted odds ratio OR 2·19 95% CI 1·43-3·34; p<0·001) and less likely to be receiving any active treatment (0·46 0·24-0·89; p=0·022) at the time of death. Women who died by suicide within versus outside the perinatal period were also more likely to be younger (crude OR -6·39 95% CI -8·15 to -4·62; p<0·0001) and married (4·46 2·93-6·80; p<0·0001), with shorter illness duration (2·93 1·88-4·56; p<0·001) and no history of alcohol misuse (0·47 0·24-0·92; p=0·027). There were no differences in service contact or treatment adherence.
In women in contact with UK psychiatric services, suicides in the perinatal period were more likely to occur in those with a depression diagnosis and no active treatment at the time of death. Assertive follow-up and treatment of perinatal women in contact with psychiatric services are needed to address suicide risk in this group.
Healthcare Quality Improvement Partnership and National Institute for Health Research.
Summary Background Research investigating which aspects of mental health service provision are most effective in prevention of suicide is scarce. We aimed to examine the uptake of key mental health ...service recommendations over time and to investigate the association between their implementation and suicide rates. Methods We did a descriptive, cross-sectional, and before-and-after analysis of national suicide data in England and Wales. We collected data for individuals who died by suicide between 1997 and 2006 who were in contact with mental health services in the 12 months before death. Data were obtained as part of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. When denominator data were missing, we used information from the Mental Health Minimum Data Set. We compared suicide rates for services implementing most of the recommendations with those implementing fewer recommendations and examined rates before and after implementation. We stratified results for level of socioeconomic deprivation and size of service provider. Findings The average number of recommendations implemented increased from 0·3 per service in 1998 to 7·2 in 2006. Implementation of recommendations was associated with lower suicide rates in both cross-sectional and before-and-after analyses. The provision of 24 h crisis care was associated with the biggest fall in suicide rates: from 11·44 per 10 000 patient contacts per year (95% CI 11·12–11·77) before to 9·32 (8·99–9·67) after (p<0·0001). Local policies on patients with dual diagnosis (10·55; 10·23–10·89 before vs 9·61; 9·18–10·05 after, p=0·0007) and multidisciplinary review after suicide (11·59; 11·31–11·88 before vs 10·48; 10·13–10·84 after, p<0·0001) were also associated with falling rates. Services that did not implement recommendations had little reduction in suicide. The biggest falls in suicide seemed to be in services with the most deprived catchment areas (incidence rate ratio 0·90; 95% CI 0·88–0·92) and the most patients (0·86; 0·84–0·88). Interpretation Our findings suggest that aspects of provision of mental health services can affect suicide rates in clinical populations. Investigation of the relation between new initiatives and suicide could help to inform future suicide prevention efforts and improve safety for patients receiving mental health care. Funding National Patient Safety Agency, UK.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
There have been concerns that the COVID-19 pandemic may lead to an increase in suicide. The coronial system in England is not suitable for timely monitoring of suicide because of the delay of several ...months before inquests are held.
We used data from established systems of "real time surveillance" (RTS) of suspected suicides, in areas covering a total population of around 13 million, to test the hypothesis that the suicide rate rose after the first national lockdown began in England.
The number of suicides in April-October 2020, after the first lockdown began, was 121•3 per month, compared to 125•7 per month in January-March 2020 (-4%; 95% CI-19% to 13%, p = 0•59). Incidence rate ratios did not show a significant rise in individual months after lockdown began and were not raised during the 2-month lockdown period April-May 2020 (IRR: 1•01 0•81–1•25) or the 5-month period after the easing of lockdown, June-October 2020 (0•94 0•81–1•09). Comparison of the suicide rates after lockdown began in 2020 for the same months in selected areas in 2019 showed no difference.
We did not find a rise in suicide rates in England in the months after the first national lockdown began in 2020, despite evidence of greater distress. However, a number of caveats apply. These are early figures and may change. Any effect of the pandemic may vary by population group or geographical area. The use of RTS in this way is new and further development is needed before it can provide full national data.
This study was funded by the Healthcare Quality Improvement Partnership (HQIP).The HQIP is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing, and National Voices. Its aim is to promote quality improvement in patient outcomes, and in particular, to increase the impact that clinical audit, outcome review programs and registries have on healthcare quality in England and Wales. HQIP holds the contract to commission, manage, and develop the National Clinical Audit and Patient Outcomes Program (NCAPOP), comprising around 40 projects covering care provided to people with a wide range of medical, surgical and mental health conditions. The program is funded by NHS England, the Welsh Government and, with some individual projects, other devolved administrations, and crown dependencies.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
•Overall child suicide deaths did not increased during the COVID-19 pandemic.•There was a possibility deaths may have temporarily increased during the first UK lockdown.•Characteristics of ...individuals were similar between periods.
There is concern about the impact of COVID-19, and the control measures to prevent the spread, on children's mental health. The aim of this work was to identify if there had been a rise of childhood suicide during the COVID pandemic.
Using data from England's National Child Mortality Database (NCMD) the characteristics and rates of children dying of suicide between April and December 2020 were compared with those in 2019. In a subset (1st January to 17th May 2020) further characteristics and possible contributing factors were obtained.
A total of 193 likely childhood deaths by suicide were reported. There was no evidence overall suicide deaths were higher in 2020 than 2019 (RR 1.09 (0.80–1.48), p = 0.584) but weak evidence that the rate in the first lockdown period (April to May 2020) was higher than the corresponding period in 2019 (RR 1.56 (0.86–2.81), p = 0.144). Characteristics of individuals were similar between periods. Social restrictions (e.g. to education), disruption to care and support services, tensions at home and isolation appeared to be contributing factors.
As child suicides are fortunately rare, the analysis is based on small numbers of deaths with limited statistical power to detect anything but major increases in incidence.
We found no consistent evidence that child suicide deaths increased during the COVID-19 pandemic although there was a possibility that they may have increased during the first UK lockdown. A similar peak was not seen during the following months, or the second lockdown.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
ObjectivesThis paper reports findings exploring work cultures, contexts and conditions associated with psychological distress in foundation and junior doctors.DesignQualitative study using in-depth ...interviews with 21 junior doctor participants. The interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.11 to facilitate data management. Data were analysed using a thematic analysis employing the constant comparative method.SettingNHS in England.ParticipantsA purposive sample of 16 female and five male junior doctor junior doctor participants who self-identified as having stress, distress, anxiety, depression and suicidal thoughts, or having attempted to kill themselves.ResultsAnalysis reported four key themes: (1) workload and working conditions; (2) toxic work cultures—including abuse and bullying, sexism and racism, culture of blaming and shaming; (3) lack of support; (4) stigma and a perceived need to appear invulnerable.ConclusionThis study highlights the need for future solutions and interventions targeted at improving work cultures and conditions. There needs to be greater recognition of the components and cumulative effects of potentially toxic workplaces and stressors intrinsic to the work of junior doctors, such as the stress of managing high workloads and lack of access to clinical and emotional support. A cultural shift is needed within medicine to more supportive and compassionate leadership and work environments, and a zero-tolerance approach to bullying, harassment and discrimination.
There is concern about the mental health of children and young people and a possible rise in suicidal behaviour in this group. We have done a comprehensive national multi-agency study of suicide in ...under 20s in England. We aimed to establish how frequently suicide is preceded by child-specific and young person-specific suicide risk factors, as well as all-age factors, and to identify contact with health-care and social-care services and justice agencies.
This study is a descriptive examination of suicide in a national consecutive sample of children and young people younger than 20 years who died by suicide in England between Jan 1, 2014, and April 30, 2015. We obtained general population mortality data from the Office for National Statistics (ONS). We collected information about antecedents considered to be relevant to suicide (eg, abuse, bullying, bereavement, academic pressures, self-harm, and physical health) from a range of investigations and inquiries, including coroner inquest hearings, child death investigations, criminal justice system reports, and the National Health Service, including data on people in contact with mental health services in the 12 months before their death.
145 suicides in people younger than 20 years were notified to us during the study period, of which we were able to obtain report data about antecedents for 130 (90%). The number of suicides rose sharply during the late teens with 79 deaths by suicide in people aged 18–19 years compared with 66 in people younger than 18 years. 102 (70%) deaths were in males. 92 (63%) deaths were by hanging. Various antecedents were reported among the individuals for whom we had report data, including academic (especially exam) pressures (35 27% individuals), bullying (28 22%), bereavement (36 28%), suicide in family or friends (17 13%), physical health conditions (47 36%), family problems (44 34%), social isolation or withdrawal (33 25%), child abuse or neglect (20 15%), excessive drinking (34 26%), and illicit drug use (38 29%). Suicide-related internet use was recorded in 30 (23%) cases. In the week before death 13 (10%) individuals had self-harmed and 35 (27%) had expressed suicidal ideas. 56 (43%) individuals had no known contact with health-care and social-care services or justice agencies.
Improved services for self-harm and mental health are crucial to suicide prevention, but the wide range of antecedents emphasises the roles of schools, primary care, social services, and the youth justice system.
The Healthcare Quality Improvement Partnership.
ObjectivesThis paper reports findings identifying foundation and junior doctors’ experiences of occupational and psychological protective factors in the workplace and sources of effective ...support.DesignInterpretative, inductive, qualitative study involving in-depth interviews with 21 junior doctor participants. The interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.11 to facilitate data management. Data were analysed using a thematic analysis employing the constant comparative method.SettingNational Health Service in the UK.ParticipantsParticipants were recruited from junior doctors through social media (eg, the British Medical Association (BMA) junior doctors’ Facebook group, Twitter and the mental health research charity websites). A purposive sample of 16 females and 5 males, ethnically diverse, from a range of specialities, across the UK. Junior doctor participants self-identified as having stress, distress, anxiety, depression and suicidal thoughts or having attempted to kill themselves.ResultsAnalysis identified three main themes, with corresponding subthemes relating to protective work factors and facilitators of support: (1) support from work colleagues – help with managing workloads and emotional support; (2) supportive leadership strategies, including feeling valued and accepted, trust and communication, supportive learning environments, challenging stigma and normalising vulnerability; and (3) access to professional support – counselling, cognitive–behavioural therapy and medication through general practitioners, specialist support services for doctors and private therapy.ConclusionsFindings show that supportive leadership, effective management practices, peer support and access to appropriate professional support can help mitigate the negative impact of working conditions and cultures experienced by junior doctors. Feeling connected, supported and valued by colleagues and consultants acts as an important buffer against emotional distress despite working under challenging working conditions.
Discharged psychiatric inpatients are at elevated risk of serious adverse outcomes, but no previous study has comprehensively examined an array of multiple risks in a single cohort.
We used data from ...the Danish Civil Registration System to delineate a cohort of all individuals born in Denmark in 1967–2000, who were alive and residing in Denmark on their 15th birthday, and who had been discharged from their first inpatient psychiatric episode at age 15 years or older. Each individual in the discharged cohort was matched on age and sex with 25 comparators without a history of psychiatric admission. Data linked to each individual were also obtained from the Psychiatric Central Research Register, Register of Causes of Death, National Patient Register, and the National Crime Register. We used survival analysis techniques to estimate absolute and relative risks of all-cause mortality, suicide, accidental death, homicide victimisation, homicide perpetration, non-fatal self-harm, violent criminality, and hospitalisation following violence, until Dec 31, 2015.
We included 62 922 individuals in the discharged cohort, and 1 573 050 matched comparators. Risks for each of all eight outcomes examined were markedly elevated in the discharged cohort relative to the comparators. Within 10 years of first discharge, the cumulative incidence of death, self-harm, committing a violent crime, or hospitalisation due to interpersonal violence was 32·0% (95% CI 31·6–32·5) in the discharged cohort (37·1% 36·5–37·8 in men and 27·2% 26·7–27·8 in women). Absolute risk of at least one adverse outcome occurring within this timeframe were highest in people diagnosed with a psychoactive substance use disorder at first discharge (cumulative incidence 49·4% 48·4–50·4), and lowest in those diagnosed with a mood disorder (24·4% 23·6–25·2). For suicide and non-fatal self-harm, risks were especially high during the first 3 months post-discharge, whereas risks for accidental death, violent criminality, and hospitalisation due to violence were more constant throughout the 10-year follow-up.
People discharged from inpatient psychiatric care are at higher risk than the rest of the population for a range of serious fatal and non-fatal adverse outcomes. Improved inter-agency liaison, intensive follow-up immediately after discharge, and longer-term social support are indicated.
Medical Research Council, European Research Council, and Wellcome Trust.
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