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Deaths by suicide and their relationship with general and psychiatric hospital discharge: 30-year record linkage study

  • Nadine Dougall (a1), Paul Lambert (a2), Margaret Maxwell (a1), Alison Dawson (a2), Richard Sinnott (a3), Susan McCafferty (a4), Carole Morris (a5), David Clark (a5) and Anthea Springbett (a5)...
Abstract
Background

Studies have rarely explored suicides completed following discharge from both general and psychiatric hospital settings. Such research might identify additional opportunities for intervention.

Aims

To identify and summarise Scottish psychiatric and general hospital records for individuals who have died by suicide.

Method

A linked data study of deaths by suicide, aged ⩾15 years from 1981 to 2010.

Results

This study reports on a UK data-set of individuals who died by suicide (n = 16 411), of whom 66% (n = 10 907) had linkable previous hospital records. Those who died by suicide were 3.1 times more frequently last discharged from general than from psychiatric hospitals; 24% of deaths occurred within 3 months of hospital discharge (58% of these from a general hospital). Only 14% of those discharged from a general hospital had a recorded psychiatric diagnosis at last visit; an additional 19% were found to have a previous lifetime psychiatric diagnosis. Median time between last discharge and death was fourfold greater in those without a psychiatric history. Diagnoses also revealed that less than half of those last discharged from general hospital had had a main diagnosis of ‘injury or poisoning’.

Conclusions

Suicide prevention activity, including a better psychiatric evaluation of patients within general hospital settings deserves more attention. Improved information flow between secondary and primary care could be facilitated by exploiting electronic records of previous psychiatric diagnoses.

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Copyright
Corresponding author
Nadine J. Dougall, NMAHP Research Unit, School of Nursing, Midwifery & Health, University of Stirling, Unit 13 Scion House, Stirling University Innovation Park, FK9 4NF, UK. Email: nadine.dougall@stir.ac.uk
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Declaration of interest

None.

Footnotes
References
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Deaths by suicide and their relationship with general and psychiatric hospital discharge: 30-year record linkage study

  • Nadine Dougall (a1), Paul Lambert (a2), Margaret Maxwell (a1), Alison Dawson (a2), Richard Sinnott (a3), Susan McCafferty (a4), Carole Morris (a5), David Clark (a5) and Anthea Springbett (a5)...
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eLetters

Link Suicide to Primary care outcomes

Dr Mukesh Kripalani, Psychiatrist
19 May 2014

Dougall et all article attempts to quantify the contact patients who have gone on to complete suicide, have had with our general medical and nursing colleagues (http://bjp.rcpsych.org/content/204/4/267.full). I would like to link this with Sharpe's1 piece, which include the proposed future of psychiatry as a discipline.

Risk is core business of every professional and several publications of the National Confidential Enquiry into Suicide and Homicide by People with Mental illness, highlight that 72% of those who die by suicide (between 2001 and 2011), were not in contact with mental health services in the last year before their death.

This article again highlights the importance of colleagues in generalmedical services, looking beyond their roles and aim to identify and assist early identification of vulnerable individuals if we are going to change the trends. However, it has a rather narrow focus, linking acute hospital care.

If we were to address suicide prevention adequately, we need to look at another report from the National confidential enquiries addressing primary care suicides in England (http://www.bbmh.manchester.ac.uk/cmhr/research/centreforsuicideprevention/nci/reports/SuicideinPrimaryCare2014.pdf). It suggests that 91% of patients who died by suicide had seen their GP in the last 12 months, including 47% in the last month before their death. Interviews with Gps identify lack of access to mental health services though only 8% of patients who died had been referred to specialist mental health services in the previous 12 months.

The reason I raise these concerns again is I feel with the clusteringmodel in England identified, there will be ever increasing pressure on Gpsto manage patients not deemed suitable for secondary care. Yet a majority of individuals who go on to commit suicide would not qualify for specialist mental health referral.

Moreover the crisis teams which were established via the Mental Health Policy Implementation Guide (MHPIG; Department of Health, 2001) are targeted on people with severe mental distress who might requirehospital admission. These are, in my opinion too exclusive, to deal with the substantial majority of individuals who go on the commit suicide. Clearly if three quarters of individuals who commit suicide are not in contact with mental health services, we have a significant problem. I would like to understand if similar developments in Crisis and Liaison services have been implemented in Scotland and if there has been an impactidentified.

Not that I advocate everyone who commit suicide are mentally ill. I feel we need to establish a protective network, led by primary care, to help make a dent in to these awful figures we are faced with.

Even the figure of 1585 patients committing suicide annually who havebeen in contact with mental health services a year before their death is too high (http://www.bbmh.manchester.ac.uk/cmhr/research/centreforsuicideprevention/nci/reports/impact_of_service_changes.pdf).My concern also lies with this figure increasing since the clustering model currently advocated has led to a reduction of patients managed in specialist secondary mental health services.

While in Middlesbrough crisis and home treatment team, we had attempted to accept any patient referred to us without question. However, that had major implications on staffing even though satisfaction rates forthe service from primary care were extremely high (almost 80% positive feedback). However with current funding models, I cannot believe that is sustainable.

Finally, I feel unless we link primary care QOF targets to suicide, we are unlikely to adequately achieve parity of both physical and mental health care.

1. Sharpe M, Psychological medicine and the future of psychiatry. Br J Psychiatry 2014; 204: 91-2.

2. Appleby L, Kapur N, Shaw J, Hunt IM, While D, Flynn S, et al. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Annual Report: England, Northern Ireland, Scotland and Wales. The University of Manchester, 2013.

Mukesh Kripalani

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Conflict of interest: None declared

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