Yorkshire Centre for Forensic Psychiatry, Wakefield
Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, UK
Correspondence: Dr David Owens, Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, 15 Hyde Terrace, Leeds LS2 9LT,UK
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ABSTRACT |
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Aims To determine the proportion of suicides preceded by accident and emergency attendance in the previous year.
Method We obtained the list of probable suicides in Leeds for a 38-month period, and examined the records from the citys accident and emergency departments for a year before each death.
Results Eighty-five (39%) of the 219 people who later died by suicide had attended an accident and emergency department in the year before death, 15% because of non-fatal self-harm. Final visits due to self-harm were often shortly before suicide (median 38 days), but the National Confidential Inquiry recorded about a fifth of them as not in contact with local mental health services.
Conclusions Although many suicides are preceded by recent attendance at accident and emergency departments due to non-fatal self-harm, local mental health service records may show no recent contact. Suicide prevention might be enhanced were accident and emergency departments and mental health services to work together more closely.
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INTRODUCTION |
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METHOD |
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We obtained the list of suicides for the Leeds Health District for a 5-year period from 1994. It was our intention to identify, for each suicide on the list, whether the person had attended a local accident and emergency department in the 12 months preceding suicide. Unfortunately, because of the storage arrangements for old accident and emergency records and consequent difficulties with access to them, we were not able to examine all the records for the relevant 6 years (5 years of suicides plus the year before the first suicide on our list). We were, however, able to obtain accident and emergency records for 50 consecutive months and we therefore used as our study sample the suicides that took place over 38 consecutive months between 1994 and 1997; accident and emergency records were examined for 38 months plus the 12 months prior to the first suicide in the sample.
Leeds has two large accident and emergency departments, each serving a population of around 350 000. We thereby identified, for each suicide in the 38-month period, all accident and emergency attendances in Leeds hospitals over the preceding 12 months. Where we found an accident and emergency record that was part of the final, fatal attendance at hospital, we excluded it; all the episodes here therefore represent non-fatal hospital attendances. Our study had local research ethics committee approval.
We used two standard statistical procedures in our analyses: for categorical variables we calculated the 95% confidence intervals for the difference between proportions; and for the one comparison we made for a continuous variable, we used the MannWhitney U test, because the data were not normally distributed.
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RESULTS |
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The search of records by the local mental health service for the National Confidential Inquiry determined that 91 of the 219 persons who died by suicide (42%) were in contact with its service during the year before their death. Surprisingly, more of those receiving an open verdict than of those receiving a suicide verdict had made contact with local mental health services in the preceding year (Table 2). People whose death was due to multiple injuries or to poisoning by ingestion were particularly likely to have made contact with the mental health services in the last year, while few of those who died by toxic fumes or by unusual methods had been in contact (Table 2).
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Attendance at accident and emergency departments
Of the whole sample, 85 (39%) had attended an accident and emergency
department in the year before death, 33 of them because of non-fatal self-harm
39% (33/85) of all those who came to accident and emergency, 15%
(33/219) of suicides. The 85 people made 195 visits to accident and emergency
departments. Figure 1 sets out
the reasons for attendance and the clinical details.
Table 3 shows that there was no
striking difference in attendance patterns between the genders or according to
the coroners verdict. Significantly more of those who had been in
contact with mental health services in their last year had attended accident
and emergency; this difference was almost entirely due to self-harm
attendances. People who died from toxic fumes or whose cause of death was
unascertained had generally not attended an accident and emergency department
because of self-harm in the previous year. On the other hand, of those whose
suicide was a result of ingested poisons, nearly half had previously attended
during the year about a fifth because of self-harm.
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Last attendance before death
Of the 85 people who visited accident and emergency departments in the year
before suicide, 26 (31%) did so on the last occasion as a consequence of
non-fatal self-harm 20 self-poisoning episodes and 6 self-injuries.
These 26 patients were of the same age pattern as the total group of people
who had died by suicide. Equal proportions attended the citys two
accident and emergency departments. Clinical details and management of the
cases by accident and emergency staff are shown in
Fig. 2. The final attendance
was shortly before suicide (median 38 days, interquartile range 7129)
when the reason was self-harm, but not when it was for other reasons
median 114 days (44228) (MannWhitney U=472,
P=0.005). In their last month of life 12 people (5% of all suicides
in our sample) paid a final visit to an accident and emergency department as a
result of non-fatal self-harm.
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The local mental health services searched their case records for contacts with their service in the year before suicide. Of the 26 persons whose last attendance at a local accident and emergency department before death was a consequence of non-fatal self-harm, 5 were not found by this search to have been in contact with mental health services in the year before their suicide; consequently, they were notified to the National Confidential Inquiry as not in contact. Either these episodes of self-harm did not result in contact with a mental health practitioner, or contact was made but did not find its way into mental health service records.
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DISCUSSION |
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Accuracy of the study findings
This study used two sources of data: the list of those dying by suicide,
including their contacts with local mental health services, sent to the
National Confidential Inquiry; and data on attendances drawn from clinical
records at the two local accident and emergency departments. The suicide data
will not perfectly represent all suicides and mental health service contacts
in the period of our sample, but they are the identical data that were
received by the National Confidential Inquiry and are included in the
Inquirys findings. Data drawn from accident and emergency records, on
the other hand, will contain inaccuracies and may therefore misrepresent the
relation between accident and emergency attendance and suicide. We might have
missed some attendances perhaps because of use of different patient
names, or simply as a consequence of searching for a small number of episodes
among more than half a million attendances at these large accident and
emergency departments.
We might also have failed to identify correctly whether each accident and emergency attendance was due to self-harm. Accident and emergency records are often brief and sometimes contain incomplete clinical details. Where it seemed possible that self-harm had occurred but was not recorded by the clinician or coded by the clerical staff as such, we designated the episode as not self-harm. These methodological shortcomings, inevitable though they are, seem most likely to have resulted in underestimation of the number and proportion of suicides in Leeds that were preceded by hospital attendance due to non-fatal self-harm.
For two further reasons, we also suspect that our local data underestimate the national shortfall in notification. First, we found that our local mental health services had identified a higher proportion of contacts than was the national average (42% compared with 24% nationally); perhaps the local mental health service was especially adept at tracing contacts. Second, Leeds practice might have shown an above-average rate of psychosocial assessment of self-harm cases during this period (Kapur et al, 1998), which would render the mental health service records particularly likely to show a contact around the time of a self-harm episode.
What are the shortcomings of present arrangements for care after
self-harm?
Our retrospective study demonstrates a strong link between non-fatal
self-harm and suicide. Published cohort studies have also shown a huge excess
of suicidal risk in the year following self-harm: it seems likely that between
0.5% and 2% of those treated for self-harm will die by suicide in the
following year (Hawton & Fagg,
1988; Owens et al,
2002). It was estimated in 1997, from Oxford rates, that there are
over 140 000 people attending hospital because of a self-harm episode each
year in England (Hawton et al,
1997). Simple arithmetic therefore indicates that a substantial
proportion of the 5000 suicides each year in England probably
somewhere between 700 and 2800 of them are preceded by a self-harm
episode in the preceding year.
This close tie between non-fatal and fatal episodes points to the need for great care over the psychosocial assessment and after-care arrangements for people attending hospital because of self-harm. Unfortunately, this connection has been largely disregarded by national policies. Governmental targets for suicide reduction in England started a decade ago with the Health of the Nation programme (Department of Health, 1992). They were renewed (Secretary of State for Health, 1999) and accompanied by standard setting (standard 7 in the National Service Framework for Mental Health) for local health and social care communities (Department of Health, 1999). The measures recommended for prevention of suicide have emphasised recognition and treatment of depression, better care of those with severe and enduring mental illness whether as in-patients, soon after discharge or in community follow-up and attention to in-patient facilities (Department of Health, 1993, 1999). Self-harm has hardly been mentioned.
The findings of the National Confidential Inquiry, in much the same way as the earlier policy documents, have been used to recommend suicide prevention measures in mental health services but say little or nothing about more than 150 000 patients across the UK who attend hospital after self-harm each year (Appleby et al, 1999a; Department of Health, 2001). The omission is not surprising: our study shows how the Inquirys methods are not designed to identify self-harm as an antecedent to suicide.
Across the UK, present arrangements for the psychosocial assessment and after-care of patients attending hospital as a result of self-harm are in disarray (Owens & House, 1994). There is great geographical variation in the proportions of people who receive adequate psychosocial assessment: a large majority of patients are assessed in some hospitals but only a minority in others (Kapur et al, 1998). Assessment usually falls well short of the levels of assessment and care recommended by professional bodies (Royal College of Psychiatrists, 1994; Hawton & James, 1995; Hughes et al, 1998; Head et al, 1999). Effective intervention after self-harm is difficult to establish because the evidence, largely derived from a few small studies, is too weak and inconclusive to provide pointers to best practice (Hawton et al, 1998; NHS Centre for Reviews and Dissemination, 1998).
What practical steps are suggested by this study?
Once risk factors for an adverse outcome have been identified, it is common
practice for policy-makers to propose alterations in practice to be
instituted with immediate effect. The findings of the National Confidential
Inquiry into suicides have been criticised for this approach
(Geddes, 1999) because of the
poor predictive validity of the risk factors. How useful is identification of
a self-harm episode likely to be? Even though people who self-harm may be at a
hundred times the baseline risk (Hawton
& Fagg, 1988; Owens et
al, 2002), suicide in the year following non-fatal self-harm
is uncommon in absolute terms: most people attending accident and emergency
departments because of self-harm are unlikely to die by suicide in the year
that follows. Low specificity of the predictive factor and low prevalence of
the outcome bring about a poor positive predictive value: interventions for
all will be unnecessary for most and will help only a few.
Taking this epidemiological axiom into account, we recommend only two steps. First, hospitals should, whenever possible, adhere to present governmental policy: that all self-harm patients receive, before discharge from hospital, a psychosocial assessment from a member of staff specifically trained for this task (Department of Health and Social Security, 1984). This assessment, and the ensuing decisions about after-care, should become part of the patients clinical record held by or made available to the mental health service. These contacts and assessments would thereby become available to the process of monitoring and audit of suicides by the National Confidential Inquiry. Second, because it is inevitable that a proportion of patients will receive no such assessment, the National Confidential Inquiry must record the occurrence of hospital attendance after self-harm. Only in this way can we evaluate the relation of non-fatal self-harm to suicide; all the present indications suggest that important links are not being made between general hospital and mental health services, and are being missed by policy-makers.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication May 14, 2002. Revision received December 11, 2002. Accepted for publication January 6, 2003.
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