National Confidential Inquiry into Suicide and Safety in Mental Health

Professor Louis Appleby 2018 NCISH Annual Report Professor Louis Appleby

Annual Report 2018 Annual update of key figures on suicide, homicide, and sudden death Messages on safer care Final year 2016 (equates to ONS 2016-17) Final year contains estimates to allow for delayed returns DONE

Collecting NCISH data All potential cases nationally (e.g. ONS, GRO (N. Ireland and Scotland), Homicide Index) Contact with mental health services Detailed data collection via questionnaire DONE

Key findings: suicide

Suicide 2006-2016 Scotland 8,601 suicide deaths 2,658 (31%) patients Northern Ireland 2,956 suicide deaths 794 (27%) patients England 49,654 suicide deaths 13,698 (28%) patients Wales 3,491 suicide deaths 781 (22%) patients DONE UK_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Suicide rates in the general population, UK Highest rate in Northern Ireland Rate in England at historical low UK_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Age-specific suicide rates, UK DONE UK_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Rates in STP ‘footprint’ areas (2014-16) Variation by geography Highest rates in north & south west Lowest rates in London & south-central areas High rates in rural & coastal areas DONE

Trends in patient suicide

Patient suicides, UK No change Falling Increased DONE UK_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Patient suicide rates, England Falling rates. i.e. adjusted for more people under mental health care ENGLAND_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Method of suicide

main causes of death, England Patient suicide: main causes of death, England ENGLAND_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Patient suicide method, UK Hanging commonest method Fall in self-poisoning Self-poisoning as common as hanging in Scotland UK_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Suicide by self-poisoning, England Deaths by self-poisoning (n=3,095)  Substance N % Opiates/opioids (prescribed & illicit) - opiates only - paracetamol/opiate compound   947 746 201 33% 26% 7% Non-opiate analgesics 205 Antipsychotics 302 11% Antidepressants - tricyclics - SSRI/SNRIs - other antidepressants 587 271 260 56 21% 9% 2% ENGLAND_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Changes in clinical settings

In-patient suicide, England Fall has slowed 31% 11% 2006-10 2012-16 Need to strengthen: ward safety care planning ENGLAND_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Suicide under CRHT, England >2x as many suicides under CRHT as in in-patients 1/3 recently discharged from hospital >1/3 under CRHT for <1 week DONE 2x as many ENGLAND_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

after discharge, England Suicides per week after discharge, England Highest risk on day 3 ENGLAND_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Alcohol & drug misuse, England 56% patients with either alcohol or drug misuse, UK Minority under specialist services What about this slight rise since 2015? Update commentary ENGLAND_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Themes in this year’s report

Suicide in female patients, UK 15,634 suicides by females over report period 38% were patients ½ aged 35-45 years UK_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Suicide in female patients Suicide by self-poisoning more common in women (35%) 74% history of self-harm, esp. younger women (89%) Affective disorder & personality disorder most common diagnoses 42% history of self-harm & co-morbid condition UK_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

recent history of self-harm Patient suicide: recent history of self-harm 29% patients had recent history of self-harm 76% seen as low risk UK_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Suicide in people aged <20 Themes of bereavement, bullying, physical health, self-harm ¼ suicide-related internet use 40% no service contact PEOPLE YOUNGER THAN 20 (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Student suicide (aged 18-21), England & Wales 12% were patients; lower than non-student patients (21%) Highest risk in January & April Low rates of some common risk factors, e.g. alcohol & drug misuse Note-left it like this because of the report where this same graph is included STUDENT_SUICIDE (2006-2016) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Clinical messages

Reducing suicide by in-patients Clinical messages (1) Reducing suicide by in-patients Safer care Improving physical safety on ward Care plans in place Strengthen nursing observation Follow-up within 2-3 days post-discharge Safer prescribing Reducing alcohol & drug misuse

Clinical messages (2) Female patients Recent self-harm Treatment of depression, following guidelines Improving personality disorder services Care of women with complex problems Rise of recent self-harm Associated with age & gender Strong warning of suicide risk

Clinical messages (3) Young people Promoting mental health in education Shared role for frontline services Availability of support at times of risk

‘10 ways’ to improve safety

Sudden unexplained death

Sudden unexplained deaths, England & Wales 31 deaths on average per year Linked to physical health, especially cardiovascular & respiratory diseases ¼ aged under 45 less physical ill- health more poly- pharmacy ENGLAND & WALES_SUDS (2005-2015) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

20 Years of the Homicide Inquiry 35

Patient homicides in the UK, 1997-2016 11% patients, 71 per year 6% schizophrenia, 37 per year Around half followed loss of contact or treatment non-adherence UK_HOMICIDE (1997-2016) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Homicide: alcohol and drugs Alcohol & drugs contribute to 45% of all homicides in England & Wales. Most patients (89%) had co-existing substance misuse (1997-2016). Prevention should focus on individual & public health measures to influence alcohol & substance misuse. 37 37

Stranger homicide 24% of homicides the victim & offender were not known to each other. Alcohol contributed to the offence in 54% and drugs in 24%. Victims of patient homicide less likely to be strangers compared to non-patients

Victims of homicide 90 patient victims of homicide between 2003-2005, 30 per year. Patients were 2.6 times more likely to be a victim of homicide. 32% of patient victims were killed by another patient. 39

National Confidential Inquiry into Suicide and Safety in Mental Health www.manchester.ac.uk/ncish @NCISH_UK