Dr Kirsten WindfuhrSenior Research Fellow & Senior Project Manager

National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH)

Centre for Mental Health and Risk

February 4 2015Cheshire & Merseyside Suicide Reduction Summit

Improving services, reducing suicide

Suicide prevention is an imperative

What are the causes of suicide?

Suicidal

Behaviour

Biological factors•Genes•Neurodevelopment

Clinical factors•Mental illness•Physical illness•Previous suicidal behaviour•Drugs and alcohol•Treatment

Psychological factors•Problem solving•Hopelessness•Impulsivity•Aggression

Environmental factors•Early life experience•Life events•Socio-economic conditions•Societal attitudes•Availability of methods(Adapted from Gunnell and Lewis 2005)

UK England Wales Scotland N. Ireland

Generalpopulation 100,329 78,170 5,475 13,235 3,449

NCISH

In contactwith MHservices

26,216

(26%)

20,300

(26%)

1,260

(23%)

3,705

(28%)

951

(28%)

Suicide in the UK; 1996/7-2012

UK_SUICIDE © 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.

What are national and local trends?

Source: Public Health England; Health Profileshttp://www.phoutcomes.info/profile/health-profiles/data#gid/1938132696/pat/6/ati/102/page/4/par/E12000002/are/E08000003

Suicide prevention and primary care

“GPs can make a big difference to overall suicide rates.” (DH, 2014)

“Primary care services have a crucial role in addressing mental health problems and assessing suicide risk.”

“The RCGP/RCPsych have issued a helpful factsheet on managing suicide risk in primary care.”

“Research is essential to inform effective suicide prevention.”

Why are GPs central to reducing suicide?

1. Majority of people present to their GP prior to losing their life to suicide

1: GP contact prior to suicide

GP contact: month prior to suicide

GP contact: year prior to suicide

Luoma et al., 2002 Am J Psychiatry

Why are GPs central to reducing suicide?

1. Majority of people present to their GP prior to losing their life to suicide

2. A substantial proportion of people with mental illness are managed in primary care

Why are GPs central to reducing suicide?

1. Majority of people present to their GP prior to losing their life to suicide

2. A substantial proportion of people with mental illness are managed in primary care

3. Suicide risk is greater in the context of mental illness

3: Suicide risk and mental illness

Year prior to suicide: mental health patient suicide deaths

Pearson et al., 2009, BJGP

Proportion of suicide deaths who had a mental illness prior to death

Cavanagh et al., 2003, Psych Med

• Study of attendance and clinical factors

• 10 years

• Case control study in primary care

• Clinical Practice Research Datalink (CPRD)

Attendance

Patients who died by suicide: consultation, diagnosis, treatment, and referral

Face-to-face GP consultation within 12months of suicide [number= 1,504 (63%)]

Clin

ical ti

me lin

e

2,384 patients who died by suicide

Number of consultations in the 12 months prior to suicide

880246

184183

128114

779181

664646

253020

48403445

0 200 400 600 800 1000

0123456789

1011121314

15-1617-1920-24

>24

Number of suicides

1,504

Risk and GP attendance frequency

12.3

7.8

Number of consultations in the time period prior to suicide

Risk and GP attendance frequency

12.3

7.8

1.67

Characteristics of non-attenders:•male•younger

Suicide risk in primary care

• Attendance – frequent attendance– increasing attendance– non-attendance

Diagnosis

Patients who died by suicide: consultation, diagnosis, treatment, and referral

Face-to-face GP consultation within 12 months of suicidenumber= 1,504 (63%)

Mental health diagnosis (any time)[number= 1,497 (63%)]

Clin

ical ti

me lin

e

2,384 patients who died by suicide

Diagnosis• Mental health diagnosis (at any time)

– 63% (v. 28% of living patients)– mainly depression

• Of patients with no diagnosis (37%)– male– 35-44

Suicide risk in primary care

• Attendance – frequent attendance– increasing attendance– non-attendance

• Diagnosis– under-recognition

Drug treatment

Patients who died by suicide: consultation, diagnosis, treatment, and referral

Face-to-face GP consultation within 12 months of suicidenumber= 1,504 (63%)

Mental health diagnosis (any time)number= 1,497 (63%)

Psychotropic drug treatment within 12 months of suicide [number= 1,148 (48%)]C

lin

ical ti

me lin

e

2,384 patients who died by suicide

Managing mental illness: suicide risk and multiple drug prescriptions

0

10

20

30

40

50

60

70

80

90

0 1 2 3 4 5 ormore

Risk

Number of drug groups

• 5x more likely to have psychotropic drugs prescribed

• 31% prescribed 2+

• elevated risk with 4 or 5

Drug treatment

• Multiple drug types

– Illness severity

– Inherent risks with complex prescribing

• Risk

Suicide risk in primary care

• Attendance – frequent attendance– increasing attendance– non-attendance

• Diagnosis– under-recognition

• Drug prescriptions– multiple drug types

Key messages for services• Markers of risk include

– frequent attendance – increasing attendance– non-attendance– multiple drug prescriptions

• Markers could form basis of ‘flag’ alert in primary care records– further assessment, engagement

• Collaborative working with third sector, on-line support

National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

Website:

http://www.manchester.ac.uk/nci

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