Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford
ICRF/NHS Centre for Statistics in Medicine, Institute of Health Sciences, Oxford
School of Psychiatry and Behavioural Sciences, University of Manchester, Withington Hospital, Manchester
Department of Psychological Medicine, John Radcliffe Hospital, Oxford
Correspondence: Professor Keith Hawton, Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford OX37JX. E-mail: keith.hawton{at}psych.ox.ac.uk
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ABSTRACT |
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Aims To assess the impact of the Princess's death on suicide and deliberate self-harm (DSH).
Method Analysis, using Poisson regression, of the number of suicides and open verdicts (suicides) in England and Wales following the Princess's death compared to the 3 months beforehand, and the equivalent periods in 1992-1996. Similar analysis on DSH presentations to a general hospital.
Results Suicides increased during the month following the Princess's funeral (+17.4%). This was particularly marked in females (+33.7%), especially those aged 25-44 years (+45.1%). Suicides did not fall in the week between the death and the funeral. Presentations for DSH increased significantly during the week following the death (+44.3%), especially in females (+65.1%). Examination of case notes suggested that the influence of the death was largely through amplification of personal losses or exacerbation of existing distress.
Conclusions The death of a major public figure can influence rates of suicidal behaviour. For DSH, the impact may be immediate, but for suicide it may be delayed.
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INTRODUCTION |
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METHOD |
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Deliberate self-harm
All cases of deliberate self-poisoning or self-injury presenting to the
general hospital in Oxford, identified through the Oxford Monitoring System
for Attempted Suicide (Hawton et
al, 1997), were analysed. These data were similarly
amalgamated into weekly counts.
Statistical analysis
Poisson regression was used to estimate the extent of any deviation in
mortality and DSH following the death of the Princess, compared with mortality
and DSH in the preceding 3 months in 1997. To control for seasonal variation
and secular trends, including a recent decline in suicide
(Kelly & Bunting, 1998) and
an increase in DSH (Hawton et al,
1997), any changes were compared with those observed in the
equivalent periods in 1992-1996.
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RESULTS |
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The overall increase in the number of suicides in both men and women during the month following the funeral, compared to the number observed during the same period in 1992-1996, was approximately 40.
Deliberate self-harm
During the first week after the Princess's death there was an apparent rise
in frequency of DSH (see Fig.
1(b)). The number of episodes of DSH exceeded the expected value
by 44.3% (95% CI -3.6 to 116.0, P=0.075). The excess in females was
65.1% (95% CI -1.4 to 176.5, P=0.056), but only 19.6% (95% CI -37.5
to 129.2, P=0.6) in males. During the 4 weeks following the funeral
there was no evidence of a major increase in DSH presentations, either overall
(+2.0%; 95% CI -19.3 to 29.1, P=0.9) or in females (+10.6%; 95% CI
-18.9 to 50.9, P=0.5) and males (-8.2%; 95% CI -35.9 to 31.5,
P=0.6), taken separately. However, as found for suicide, there was an
excess of episodes in females in the fourth week after the funeral (69.6%; 95%
CI -3.8 to 198.9, P=0.068). There were insufficient numbers in
specific age groups to conduct an analysis of DSH episodes by age.
Case notes examination in DSH patients
Scrutiny of the case notes for 116 patients who presented to the hospital
in Oxford following DSH during the 5 weeks after the death of the Princess,
and were assessed by the general hospital psychiatric service, revealed that
in nine (7.8%) cases (all involving overdoses) there was mention of Princess
Diana's death as contributing to the DSH
(Table 1). All but one occurred
in the first 9 days after the death. Two-thirds were male. The apparent
influence of the Princess's death varied
(Table 1), the two most
prominent themes being amplification of the impact of other losses, and
general distress about the death in the context of other difficulties.
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DISCUSSION |
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There was no evidence of a decline in suicides in the week following the death of the Princess, as might be expected from apparently greater social cohesion (Durkheim, 1897). The increase in the number of suicides occurred in the month following the funeral, when depressive disorders may have been amplified or precipitated in vulnerable individuals. In contrast, DSH presentations increased substantially only in the week following the Princess's death. Since many acts of DSH are impulsive, one might have expected the impact to be more immediate, and the review of the DSH case notes supports this.
The increase in both suicide and DSH following the Princess's death was mainly found for females. The suicides occurred particularly in the age range which included the Princess's age (36 years), suggesting a specific modelling effect (Bandura, 1973), in keeping with findings for media influence on suicide (Schmidtke & Schaller, 2000). The increase in the number of suicides and DSH episodes in females in the fourth week after the funeral is difficult to explain. The increase in suicides in the month following the funeral appeared to relate to individuals who were in contact with psychiatric services as well as those who were not, since, according to data from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (Appleby et al, 1999), there was no change during this period in the proportion of suicides known to mental health services.
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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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Bandura, A. (1973) Aggression: a Social Learning Analysis. Englewood Cliffs, NJ: Prentice-Hall.
Biller, O. A. (1977) Suicide related to the assassination of President John F. Kennedy. Suicide and Life Threatening Behavior, 7, 40-44.[Medline]
Bollen, K. A. & Phillips, D. P. (1982) Imitative suicides: a national study of the effects of television news stories. American Sociological Review, 47, 802-809.
Bunch, J. (1972) Recent bereavement in relation to suicide. Journal of Psychosomatic Research, 16, 361-366.[CrossRef][Medline]
Durkheim, E. (1897) Le Suicide. English transl. 1951. Glencoe, IL: Free Press.
Hawton, K., Fagg, J., Simkin, S., et al (1997) Trends in deliberate self-harm in Oxford, 1985-1995. Implications for clinical services and the prevention of suicide. British Journal of Psychiatry, 171, 556-560.[Abstract]
Kelly, S. & Bunting, J. (1998) Trends in suicide in England and Wales, 1982-96. Population Trends, 92, 29-41.[Medline]
Schmidtke, A. & Schaller, S. (2000) The role of mass media in suicide prevention. In The International Handbook of Suicide and Attempted Suicide (eds K. Hawton & K. Van Heeringen), pp. 675-697. Chichester: John Wiley & Sons.
World Health Organization (1977) Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death (9th revision) (ICD-9). Geneva: WHO.
Received for publication December 6, 1999. Revision received April 5, 2000. Accepted for publication April 7, 2000.