1. Suicide and self-harm in people with bipolar disorder Better Care for People with Bipolar Disorder Manchester January 2015 Nav Kapur The Centre for Suicide Prevention University of Manchester

2. Suicide and self-harm in people with bipolar disorder 1.Context 2.Suicide in bipolar disorder 3.Self-harm in bipolar disorder 4.Qualitative work With special thanks to Caroline Clements This presentation presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (Reference number RP-PG- 0407-10389). The views expressed are those o fthe author(s) and not necessarily those of the NHS, the NIHR or the Dept. Of Health. NK is also supported by Manchester Mental Health and Social Care Trust.

3. Suicide and self-harm in people with bipolar disorder 1.Context 2.Suicide in bipolar disorder 3.Self-harm in bipolar disorder 4.Qualitative work

4. Suicide in the UK

5. 6000 deaths per year Gender: men Age: mid-life

6. Self harm Self-poisoning or self-injury irrespective of apparent motivation or medical seriousness

7. Self-harm and suicide 50%+ of those who die by suicide have a history of self-harm Risk of suicide increased 30-50 fold in the year after self- harm

8. Self-harm and suicide Bergen et al 2012, Lancet Life expectancy in men who self-harm vs the general population 50%+ of those who die by suicide have a history of self-harm Risk of suicide increased 30-50 fold in the year after self- harm

9. Suicide in bipolar disorder

10. Average follow up 18 years Proportion of those with BPD dying by suicide 8% (men) 5% (women)

11. Studies to date Small samples Single site Hospitalised patients Limited information How do risk factors link together?

12. Aims To understand Frequency and characteristics Risk factors Processes in people with BPD who died by suicide or harmed themselves

13. Suicide and self-harm in people with bipolar disorder 1.Context 2.Suicide in bipolar disorder 3.Self-harm in bipolar disorder 4.Qualitative work

14. Suicide in bipolar disorder

15. Collecting the data (1996-2009) All potential cases nationally (suicide and open verdicts from ONS, GRO) Contact with mental health services Data collection via questionnaire

16. Findings 1489 suicide deaths in people with BPD (10% of all Inquiry deaths) Around 116 per year No trends (but suicide fell overall in the general population)

17. Variable Bipolar disorder n=1489(%) All other diagnoses n=13976(%) Duration of primary diagnosis Over 5 years1057 (71.4)6766 (50.3) Under drug/alcohol services*39(5.9)701 (11.9) More than 5 admissions to in-patient care 469 (32.4)1754 (13.3) Last contact before death <7 days904 (61.2)6577 (48.8) Immediate suicide risk none or low1230 (86.1)11004 (86.0) Prescribed lithium or mood stabilizer654 (58.2)707 (6.9) Findings Clements et al Psychological Medicine 2013

18. Fig 2 Forest plot showing meta-analysis of suicides in randomised trials comparing lithium with placebo or with active comparators. Cipriani A et al. BMJ 2013;346:bmj.f3646 ©2013 by British Medical Journal Publishing Group

19. Variable Bipolar disorder n=1489(%) All other diagnoses n=13976(%) Duration of primary diagnosis Over 5 years1057 (71.4)6766 (50.3) Under drug/alcohol services*39(5.9)701 (11.9) More than 5 admissions to in-patient care 469 (32.4)1754 (13.3) Last contact before death <7 days904 (61.2)6577 (48.8) Immediate suicide risk none or low1230 (86.1)11004 (86.0) Prescribed lithium or mood stabilizer654 (58.2)707 (6.9) Findings Clements et al Psychological Medicine 2013

20. Risk factors Inquiry case-control study of current and recent in-patients 63 people with BPD who died by suicide vs 63 people with BPD who had not died

21. Risk factors Suicide Alcohol misuse Depression Live alone Previous self- harm Life events

22. Suicide and self-harm in people with bipolar disorder 1.Context 2.Suicide in bipolar disorder 3.Self-harm in bipolar disorder 4.Qualitative work

23. Self-harm

24. The Manchester Self-Harm (MaSH) project All people presenting to three EDs in Manchester with self-harm Proformas completed by ED and mental health clinicians Clinical and service related data 103 people with bipolar disorder vs 515 controls matched on date of presentation Main outcome: repeat self-harm

25. Self-harm Clements et al Journal of Affective Disorders 2014

26. Self-harm Clements et al Journal of Affective Disorders 2014 Hazard ratio >3

27. Self-harm Clements et al Journal of Affective Disorders 2014 Hazard ratio >3 Suicide: 3.9% BPD 1.4% Controls

28. Suicide and self-harm in people with bipolar disorder 1.Context 2.Suicide in bipolar disorder 3.Self-harm in bipolar disorder 4.Qualitative work

29. Qualitative work Relatives of people with BPD who had died by suicide (n=11) People with BPD who had self- harmed (n=11)

30. Qualitative work Challenges of recruitment: NCI and MaSH databases CSOs Bipolar UK (adverts, support groups, annual conference) PARADES participants

31. Qualitative work In depth interviews England wide Interviews transcribed Thematic analysis

32. Qualitative themes Patient Communication Experience of Services Role of family

33. Qualitative themes Experience of Services the psychiatrist..…said well I can't follow her ….and there was no mechanism for transferring anything, alerting anybody. This was somebody they were sufficiently concerned about to actually go out with the intention of sectioning, you know... but no she is out of the area, there is nothing we can do about it and then of course we were sort of back to square one

34. Qualitative themes Patient Communication But on the whole, I mean the overwhelming impression was that throughout this whole period.... she was putting up this front that she was absolutely fine... there were all sorts of stuff going on but she was fine

35. Qualitative themes Role of family I mean, you must think I am a fool, I am a fool, every time he moved he needed a deposit, I paid it, I know I just wanted to try and set him up on his own and I don't know whether it did any good or it didn't but you cannot see your child struggling and suffering and I don't know whether I sometimes think you know, have I made his life worse for him.

36. Suicide and self-harm in people with bipolar disorder 1.Context 2.Suicide in bipolar disorder 3.Self-harm in bipolar disorder 4.Qualitative work With special thanks to Caroline Clements

37. Implications Clinicians should be aware of the suicide risk in those with BPD Some risks are shared Some risks may be unique What is the role of treatment in preventing suicide?