National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Suicide Prevention, Manchester, UK
Correspondence: Professor Louis Appleby, Centre for Suicide Prevention, University of Manchester, 7th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, UK
See editorial, pp.
100101, this issue.
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ABSTRACT |
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Aims To establish the number of patients from ethnic minorities who kill themselves; to describe their suicide methods, and their social and clinical characteristics.
Method A national clinical survey was based on a 4-year sample of suicides in England and Wales. Detailed data were collected on those who had been in contact with mental health services in the year before death.
Results In total 282 patients from ethnic minorities died by suicide 6% of all patient suicides. The most common method of suicide was hanging; violent methods were more common than in White patient suicides. Schizophrenia was the most common diagnosis. Ethnic minority patients were more likely to have been unemployed than White patients and to have had a history of violence and recent non-compliance. In around half, this was the first episode of self-harm. Black Caribbean patients had the highest rates of schizophrenia (74%), unemployment, living alone, previous violence and drug misuse.
Conclusions In order to reduce the number of suicides by ethnic minority patients, services should address the complex health and social needs of people with severe mental illness.
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INTRODUCTION |
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METHOD |
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Comprehensive national sample
Information on all deaths in England and Wales receiving a verdict of
suicide or an open verdict at coroner's inquest was obtained from the Office
for National Statistics (ONS). The cases presented here consist of deaths
registered by the ONS from 1 April 1996 until 31 March 2000.
In the first 3 years of the study this information was cross-checked against equivalent data from the health authorities in England and Wales; inconsistencies were rare. Open verdicts, recorded by the ONS as deaths from undetermined external cause, are often reached in cases of suicide, and some or all open verdicts are conventionally included in research on suicide (O'Donnell & Farmer 1995; Neeleman & Wessely, 1997) and in official suicide statistics. In this study open verdicts were included unless it was clear that suicide was not considered at inquest for example, in deaths from an unexplained medical cause. These suicides and probable suicides are referred to as suicides in this paper.
Identification of mental health service contact
Identifying details on each suicide were submitted to the main hospital and
the community trusts providing mental health services to people living in the
dead person's former district of residence. When trust records showed that the
person had been in contact with mental health services in the 12 months
preceding death, the suicide became an inquiry case. All local
mental health services in England and Wales returned data to the inquiry. We
arranged for cases to be directly reported from units that had multi-district
catchment areas, including regional forensic psychiatry units, or had no
catchment area, including national units and private hospitals. An assessment
of the accuracy of checks by trusts, carried out in 16 trusts in north-west
England, showed that 95% of eligible cases were identified. Missed cases arose
because of misspellings of names in trust records or in personal information
notified to the inquiry. As a result a checking protocol was developed and
recommended to trusts.
Collection of clinical data
For each inquiry case the consultant psychiatrist was sent a questionnaire
and asked to complete it after discussion with other members of the mental
health team. The questionnaire consisted of sections covering
socio-demographic characteristics, clinical history, details of suicide,
aspects of care, details of final contact with services and respondents' views
on prevention. The social and clinical items reflected many of the most
frequently reported risk factors for suicide. The majority of items were
factual; a number (e.g. compliance) were based on the judgements of
clinicians. Ethnicity was determined by clinicians, who were asked to select
from a list corresponding to current ONS categories: Black African, Black
Caribbean, Indian/Pakistani/Bangladeshi (referred to in this paper as South
Asian), Chinese, White and Other.
Statistical analysis
The main findings are presented as proportions with 95% confidence
intervals. If an item of information was not known for a case, the case was
removed from the analysis of that item; the denominator in all estimates is
therefore the number of valid cases for the item.
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RESULTS |
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A total of 282 (6%) individuals were from an ethnic minority group; that is, there were around 70 suicides per year among patients from ethnic minorities during the study period. Ninety-five (34%) were South Asian, 64 (23%) Black Caribbean, 35 (12%) Black African and 12 (4%) Chinese. The remaining 76 (27%) were classified as Other these included patients of mixed ethnic origin.
Method of suicide
Hanging, self-poisoning and jumping from a height or in front of a moving
vehicle were the main methods of suicide in all ethnic groups, but the
relative frequencies of these methods differed
(Table 1). Violent methods of
suicide were more often used by ethnic minority patients. Compared with
suicides by White people, those from an ethnic minority were more likely to
kill themselves by jumping and less likely to self-poison; these differences
were greatest for Black Caribbeans. Deaths by burning were also more common
among ethnic minority suicides. Nine (9%) of the suicides of South Asian
patients were by burning; 5 (15%) of 33 South Asian women used this method,
compared with 28 (2%) of 1547 White women.
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Social characteristics
Factors indicating social adversity were common in all ethnic groups, but
patients from ethnic minorities who completed suicide were more likely than
White patients to be unemployed (Table
2). Among the ethnic minority groups, unemployment, living alone
and being unmarried were more commonly features of Black Caribbean patients
and less commonly features of South Asian patients. In the Chinese sample
there was a preponderance of women: 58%, compared with 34% of the White sample
(P=0.08), although numbers were small (in the Chinese sample 7 out of
12 were women).
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Diagnosis
The main feature of the diagnostic profile of ethnic minority patients who
died by suicide was the large proportion with a primary diagnosis of
schizophrenia (Table 3). This
was particularly true for Black Caribbean patients: 74% (95% CI 6385)
had a diagnosis of schizophrenia compared with 18% (95% CI 1720) of the
White sample. Ethnic minority patients were less likely to have an affective
disorder, although this was the most common diagnosis in South Asian patients
(46%; 95% CI 3656).
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Clinical history
Items indicating clinical risk were common in all ethnic groups but
relative frequencies varied in the ethnic minority groups, a history
of violence was more common and a history of alcohol misuse was less common
(Table 4). In half the ethnic
minority patients the first episode of self-harm had been fatal. Violence was
reported in almost half the Black Caribbean and Black African patients; drug
misuse was reported in almost half the Black Caribbeans. Alcohol and drug
misuse were uncommon features of South Asian patient suicides.
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Clinical care
A quarter of the Black Caribbean and almost a third of the Black African
patients were in-patients at the time of death. Ethnic minority in-patients
overall were more often detained under the Mental Health Act at the time of
suicide (48%, 95% CI 3462) compared with White in-patients (26%, 95% CI
2329). However, they were no more likely to be under medium-level
(checked every 525 min) or high-level (one to one) observation at the
time of death: 19% (95% CI 731) compared with 26% (95% CI 2230).
The higher rate of detention was not simply a reflection of the greater number
of ethnic minority patients who had schizophrenia; findings were similar when
the cases of schizophrenia were analysed alone (65% v. 45%, P=0.04).
Reported non-compliance with drug treatment was a more common feature of
suicides by ethnic minorities, although loss of contact with services was no
more common. Psychotropic drug side-effects were commonly reported by Black
African patients, but not by other ethnic groups, compared with White patients
(22% v. 7%, P=0.004).
Twenty-two per cent of suicides by patients from ethnic minorities were seen by respondents as preventable. Suicides by Black Caribbean patients were most likely to be viewed as preventable. Improved compliance (42%, 95% CI 2064), closer supervision (55%, 95% CI 3377) and, in Asian suicides, contact with the patient's family (33% v. 16% of White cases, P=0.02) were the measures that might have reduced risk most often, according to respondents.
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DISCUSSION |
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Methodological issues
Several methodological limitations must be highlighted. First, this report
is a survey of clinical circumstances preceding suicide. Although uncontrolled
national studies of suicide can be informative
(Lonnqvist, 1988),
aetiological conclusions cannot be drawn without a comparison sample. For
example, the preponderance of schizophrenia in suicides by patients from
ethnic minorities cannot be taken to mean that schizophrenia carries a higher
risk in ethnic minorities. However, people with schizophrenia must be targeted
by prevention measures if the number of suicides is to be reduced. Second, the
information from clinicians was based on case records and clinical judgements
rather than standardised assessments. However, a large number of suicide
studies have relied on similar methods. In addition, the accuracy of
Confidential Inquiry questionnaire data has been shown to be good
(Appleby et al, 1999).
Third, the clinicians who provided the information were not masked and might
have been biased by their awareness of outcome. Fourth, although this was a
national sample, the numbers of people in some ethnic minority groups were
small and confidence limits are sometimes wide. Fifth, the classification of
ethnicity is problematic (McKenzie et
al, 1995) and we cannot be certain that clinicians defined
the ethnic groups in the same way; however, ethnic groups were broad and the
allocation of people to them should have been relatively reliable. Sixth,
ascertainment biases might also have been operating; for example, we cannot
rule out that the likelihood of a verdict of suicide is influenced by
ethnicity.
Clinical implications
Suicide prevention strategies need to be broad-ranging
(Mann & Hendin, 2001). The
findings of our study suggest that different suicide prevention measures will
be needed for different ethnic groups. Three-quarters of Black Caribbean
patients in the sample were suffering from schizophrenia and many showed
evidence of complex health and social needs. They were predominantly young and
male, living alone and unemployed, and many had what appeared to be turbulent
histories marked by violence, drug misuse, non-compliance and multiple
hospital admissions. The majority were already receiving care at the
enhanced (more intensive) level of the Care Programme Approach
(or its equivalent in Wales). Although the causal role of the social and
clinical antecedents is unproven in this study, the findings suggest that
suicide prevention in this group will require comprehensive packages of care
for people with severe mental illness, targeting social exclusion and risk
behaviours such as drug misuse, offering treatments that are acceptable and
encouraging compliance.
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Clinical Implications and Limitations |
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LIMITATIONS
In contrast, South Asian patients who died by suicide were most likely to be suffering from affective disorder. Only 20% were living alone and almost half were married. A history of alcohol or drug misuse was unusual. However, non-compliance with treatment was as common as in the Black Caribbean group. In people of South Asian origin it may be important to ensure that depression is adequately treated, making use of the available family environments to encourage compliance and report signs of risk.
This study found that the Black patient groups had the greatest proportion of suicides during hospitalisation, although the finding is of borderline statistical significance with this sample size. Among inpatient suicides, ethnic minority patients were more likely to be detained under mental health legislation, but this apparent need to ensure safety did not translate into greater use of close or constant observation. The high rate of detention and compulsory treatment in ethnic minority patients remains a cause of concern (Goater et al, 1999). More broadly, variations in risk management across ethnic groups need to be explored further.
Cultural patterns of suicide
A male preponderance is an almost universal finding in suicide research. In
contrast, our finding of a higher number of female suicides in Chinese
patients is in line with reports on suicide in China
(Zhao et al, 1994),
although the number of people in this group was small. Our results also
confirm previous reports that suicide by burning, although generally uncommon
in England and Wales, is relatively common in South Asian women
(Soni Raleigh & Balarajan,
1992; Prosser,
1996).
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ACKNOWLEDGMENTS |
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Received for publication July 5, 2002. Revision received October 7, 2002. Accepted for publication October 21, 2002.
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