Suicide in women in the UK is highest among those in midlife. Given the unique changes in biological, social and economic risk factors experienced by women in midlife, more information is needed to inform care.

To investigate rates, characteristics and outcomes of self-harm in women in midlife compared to younger women and identify differences within the midlife age-group.

Data on women aged 40–59 years from the Multicentre Study of Self-harm in England from 2003 to 2016 were used, including mortality follow-up to 2019, collected via specialist assessments and/or emergency department records. Trends were assessed using negative binomial regression models. Comparative analysis used chi-square tests of association. Self-harm repetition and suicide mortality analyses used Cox proportional hazards models.

The self-harm rate in midlife women was 435 per 100 000 population and relatively stable over time (incident rate ratio (IRR) 0.99, p < 0.01). Midlife women reported more problems with finances, alcohol and physical and mental health. Suicide was more common in the oldest midlife women (hazard ratio 2.20, p < 0.01), while psychosocial assessment and psychiatric inpatient admission also increased with age.

Addressing issues relating to finances, mental health and alcohol misuse, alongside known social and biological transitions, may help reduce self-harm in women in midlife. Alcohol use was important across midlife while physical health problems and bereavement increased with age. Despite receiving more intensive follow-up care, suicide risk in the oldest women was elevated. Awareness of these vulnerabilities may help inform clinicians’ risk formulation and safety planning.

An improved understanding of the factors associated with self-harm in young people who die by suicide can inform suicide prevention measures.

To describe sociodemographic and clinical characteristics and service utilisation related to self-harm in a national sample of young people who died by suicide.

We carried out a descriptive study of self-harm in a national consecutive case series (N = 544) of 10- to 19-year-olds who died by suicide over 3 years (2014–2016) in the UK as identified from national mortality data. Information was collected from coroner inquest hearings, child death investigations, criminal justice system and National Health Service serious incident reports.

Almost half (49%) of these young people had harmed themselves at some point in their lives, a quarter (26%) in the 3 months before death. Girls were twice as likely as boys to have recent self-harm (40 v. 20%; P < 0.001). Compared to the no self-harm group, young people with recent self-harm were more likely to have a mental illness diagnosis (63 v. 23%; P < 0.001); misused alcohol (19 v. 9%; P = 0.07); experienced physical, sexual or emotional abuse (17 v. 3%; P < 0.01); and recent life adversity (95 v. 75%; P < 0.001). Furthermore, they were more likely to be in contact with mental health services (60 v. 10%), or emergency departments or general physicians for a mental health condition (52 v. 10%) in the 3 months before death.

Presentation to services in young people who self-harm is an important opportunity to intervene through comprehensive psychosocial assessment and treatment of underlying conditions.

Tackling methods of suicide and limiting access to lethal means remain priority areas of suicide prevention strategies. Although mental health services are a key setting for suicide prevention, no recent studies have explored methods used by mental health patients.

To investigate associations between main suicide methods and social, behavioural and clinical characteristics in patients with mental illness to inform prevention and improve patient safety.

Data were collected as part of the National Confidential Inquiry into Suicide and Safety in Mental Health. We examined the main suicide methods of 26 766 patients in the UK who died within 12 months of contact with mental health services during 2005–2021. Associations between suicide methods and patient characteristics were investigated using chi-square tests and univariate and multivariate logistic regression.

Suicide methods were associated with particular patient characteristics: hanging was associated with a short illness history, recent self-harm and depression; self-poisoning with substance misuse, personality disorder and previous self-harm; and both jumping and drowning with ethnic minority groups, schizophrenia and in-patient status.

A method-specific focus may contribute to suicide prevention in clinical settings. Hanging deaths outside of wards may be difficult to prevent but our study suggests patients with recent self-harm or in the early stages of their illness may be more at risk. Patients with complex clinical histories at risk of suicide by self-poisoning may benefit from integrated treatment with substance use services. Environmental control initiatives are likely to be most effective for those at risk of jumping or drowning.

Suicide-related internet use (SRIU), defined as internet use related to one's own feelings of suicide, can be both a risk and protective factor, especially for isolated individuals. Despite its influence on suicidality, clinicians face challenges in assessing SRIU because of the private nature of internet usage. Current recommendations on enquiring about SRIU in a clinical setting concern mostly young people.

To address the gap in understanding SRIU among patients of all ages, this study aims to explore mental health clinicians’ experiences, attitudes and beliefs regarding enquiring about SRIU, as well as the risks and benefits it presents in the assessment and management of patients. Finally, the study aims to establish the role SRIU potentially plays in the assessment and management of patients.

Twelve clinicians practising at secondary mental health services in England participated in interviews. Thematic analyses were used for data interpretation.

Clinicians who participated in interviews rarely initiate discussions on SRIU with their patients despite considering this an important factor in suicidality. Age of both patients and clinicians has the potential to influence enquiry into SRIU. Clinicians recognise the potential benefits of patients finding supportive online communities but also express concerns about harmful and low-quality online content related to suicide.

Integrating SRIU enquiry into standard clinical practice, regardless of the patient's age, is an important step towards comprehensive patient care. Broader training for clinicians on enquiring about online behaviours is essential to mitigate potential risks and harness the benefits of SRIU in mental health patients.

People under the care of mental health services are at increased risk of suicide. Existing studies are small in scale and lack comparisons.

To identify opportunities for suicide prevention and underpinning data enhancement in people with recent contact with mental health services.

This population-based study includes people who died by suicide in the year following a mental health services contact in Wales, 2001–2015 (cases), paired with similar patients who did not die by suicide (controls). We linked the National Confidential Inquiry into Suicide and Safety in Mental Health and the Suicide Information Database – Cymru with primary and secondary healthcare records. We present results of conditional logistic regression.

We matched 1031 cases with 5155 controls. In the year before their death, 98.3% of cases were in contact with healthcare services, and 28.5% presented with self-harm. Cases had more emergency department contacts (odds ratio 2.4, 95% CI 2.1–2.7) and emergency hospital admissions (odds ratio 1.5, 95% CI 1.4–1.7), but fewer primary care contacts (odds ratio 0.7, 95% CI 0.6–0.9) and out-patient appointments (odds ratio 0.2, 95% CI 0.2–0.3) than controls. Odds ratios were larger in females than males for injury and poisoning (odds ratio: 3.3 (95% CI 2.5–4.5) v. 2.6 (95% CI 2.1–3.1)).

We may be missing existing opportunities to intervene, particularly in emergency departments and hospital admissions with self-harm presentations and with unattributed self-harm, especially in females. Prevention efforts should focus on strengthening routine care contacts, responding to emergency contacts and better self-harm care. There are benefits to enhancing clinical audit systems with routinely collected data.

Psychiatric in-patients have a greatly elevated risk of suicide. We aimed to examine trends in in-patient suicide rates and determine if characteristics of in-patients who died by suicide have changed over time.

We identified all in-patients in England who died by suicide between 2009 and 2020 from the National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide rates were calculated using data from Hospital Episodes Statistics.

The rate of in-patient suicide per 100 000 bed days fell by 41.9% between 2009–2011 and 2018–2020. However, since 2016 the rate has remained static with no significant fall. Rates fell in men, those aged 30–59, and those with schizophrenia and other delusional disorders or personality disorder. Rates also fell for suicide by hanging (including hanging on the ward) and jumping. No falls were seen in suicide rates among women, younger and older age groups, and those with affective disorder. There was no indication of a transfer of risk to the post-discharge period or to home treatment/crisis care. More in-patients in the latter part of the study were aged under 25, were on authorised leave, and had psychiatric comorbidity.

In-patient suicide has significantly fallen since 2009, suggesting patient safety may have improved. The recent slowdown in the fall in rates, however, highlights that renewed preventative efforts are needed. These should include a greater focus on women, younger and older patients, and those with affective disorder. Careful reviews prior to granting leave are important to ensure a safe transition into the community.

Evidence attests a link between junior doctors’ working conditions and psychological distress. Despite increasing concerns around suicidality among junior doctors, little is known about its relationship to their working conditions.

To (a) establish the prevalence of suicidal ideation among junior doctors in the National Health Service; (b) examine the relationships between perceived working conditions and suicidal ideation; and (c) explore whether psychological distress (e.g. symptoms of depression and anxiety) mediates these relationships.

Junior doctors were recruited between March 2020 and January 2021, for a cross-sectional online survey. We used the Health and Safety Executive's Management Standards Tool; Depression, Anxiety and Stress Scale 21; and Paykel Suicidality Scale to assess working conditions, psychological distress and suicidality, respectively.

Of the 424 participants, 50.2% reported suicidal ideation, including 6.1% who had made an attempt on their own life. Participants who identified as LGBTQ+ (odds ratio 2.18, 95% CI 1.15–4.12) or reported depression symptoms (odds ratio 1.10, 95% CI 1.07–1.14) were more likely to report suicidal ideation. No direct relationships were reported between working conditions (i.e. control, support, role clarity, strained relationships, demand and change) and suicidal ideation. However, depression symptoms mediated all six relationships.

This sample of junior doctors reported alarming levels of suicidal ideation. There may be an indirect relationship between working conditions and suicidal ideation via depressive symptoms. Clearer research exploring the experience of suicidality in junior doctors is needed, including those who identify as LGBTQ+. Systematic interventions addressing working environment are needed to support junior doctors’ mental health.

People who experience homelessness are thought to be at high risk of suicide, but little is known about self-harm in this population.

To examine characteristics and outcomes in people experiencing homelessness who presented to hospital following self-harm.

Data were collected via specialist assessments and/or hospital patient records from emergency departments in Manchester, Oxford and Derby, UK. Data were collected from 1 January 2000 to 31 December 2016, with mortality follow-up via data linkage with NHS Digital to 31 December 2019. Trend tests estimated change in self-harm over time; descriptive statistics described characteristics associated with self-harm. Twelve-month repetition and long-term mortality were analysed using Cox proportional hazards models and controlled for age and gender.

There were 4841 self-harm presentations by 3270 people identified as homeless during the study period. Presentations increased after 2010 (IRR = 1.09, 95% CI 1.04–1.14, P < 0.001). People who experienced homelessness were more often men, White, aged under 54 years, with a history of previous self-harm and contact with psychiatric services. Risk of repetition was higher than in domiciled people (HR = 2.05, 95% CI 1.94–2.17, P < 0.001), as were all-cause mortality (HR = 1.45, 95% CI 1.32–1.59. P < 0.001) and mortality due to accidental causes (HR = 2.93, 95% CI 2.41–3.57, P < 0.001).

People who self-harm and experience homelessness have more complex needs and worse outcomes than those who are domiciled. Emergency department contact presents an opportunity to engage people experiencing homelessness with mental health, drug and alcohol, medical and housing services, as well as other sources of support.

Community treatment orders (CTOs) enable patients to be treated in the community rather than under detention in hospital. Population-based studies of suicide among patients subject to a CTO are scarce.

To compare suicide rates among patients subject to a CTO with all discharged psychiatric patients and those detained for treatment but not subject to a CTO at discharge (‘CTO-eligible’ patients).

From a national case series of patients who died by suicide within 12 months of contact with mental health services in England during 2009–2018, we estimated average annual suicide rates for all discharged patients, those on a CTO at the time of suicide, those ever treated under a CTO and CTO-eligible patients.

Suicide rates for patients on a CTO at the time of suicide (191.3 per 100 000 patients) were lower than all discharged patients (482.3 per 100 000 discharges). Suicide rates were similar in those ever treated under a CTO (350.1 per 100 000 CTOs issued) and in CTO-eligible patients (382.9 per 100 000 discharges). Suicide rates within 12 months of discharge were higher in persons ever under a CTO (205.1 per 100 000 CTOs issued) than CTO-eligible patients (161.5 per 100 000 discharges), but this difference was reversed for rates after 12 months of discharge (153.2 per 100 000 CTOs issued v. 223.4 per 100 000 discharges).

CTOs may be effective in reducing suicide risk. The relative benefits of CTOs and intensive aftercare may be time-dependent, with the benefit of a CTO being less before 12 months after discharge but greater thereafter. CTO utilisation requires a careful balancing of patient safety versus autonomy.

Homelessness in England and Wales is on the rise together with the mortality rate among homeless people. Many homeless people have a mental illness, which is a risk factor for suicide.

This study used data from the National Confidential Inquiry into Suicide and Safety in Mental Health to examine demographic and clinical characteristics of homeless people who died by suicide and were in recent contact with mental health services.

We have compared 514 patients (2% of the total sample) who died by suicide and who were reported as being homeless or having no fixed abode by their clinicians with patients in stable accommodation between 2000 and 2016 to identify differences in sociodemographic characteristics and clinical care.

Our analysis suggests that homeless patients who died by suicide had more acute (alcohol: 47% v. 25%, P < 0.01, drug: 39% v. 15%, P < 0.01) and chronic (alcohol: 72% v. 44%, P > 0.01, drug: 64% v. 31%) substance misuse issues than patients in stable accommodation. Homeless patients were also more likely to die as in-patients (21% v. 10%, P < 0.01) or within 3 months of discharge (32% v. 19%, P < 0.01).

Homeless patients who died by suicide more often had known risk factors for suicide than patients in stable accommodation. As a result of the higher percentages of post-discharge and in-patient suicides in homeless patients as well as the high prevalence of substance misuse, this study recommends closer integration of services as well as awareness of risks during in-patient admission and in the weeks immediately after discharge.

Some people diagnosed with schizophrenia are more prone to committing acts of serious violence, especially in the presence of drug or alcohol misuse. The rarity of homicide has meant that no large controlled study has previously examined clinical risk factors.

To determine the risk factors for homicide by males diagnosed with schizophrenia.

A national nested case–control study of all previously admitted males diagnosed with schizophrenia, convicted of homicide between 1 January 1997 and 31 December 2012. Univariate and multivariable conditional logistic regression models were fitted to identify predictors of homicide in this population.

During the observation period 160 male patients with schizophrenia and a history of psychiatric admission were convicted of homicide, and they were matched with 542 male control patients who had not been convicted of homicide. Patients who committed homicide were more likely to have a history of violence and comorbid personality disorder or drug misuse. They were more likely to have missed their last contact with services prior to the offence and to have been non-adherent with their treatment plan. Almost all (94%) of homicides were committed by patients who had a history of alcohol or drug misuse and/or who were not in receipt of planned treatment.

In England and Wales, homicides by patients with schizophrenia without substance misuse and in receipt of planned care are exceptionally rare. To prevent serious violence, mental health services should focus on drug and alcohol misuse, treatment adherence and maintaining contact with services.

Homicide rates have fallen markedly in the UK over the past decade. There has been little research on whether homicides by people with mental disorder have contributed to this downward trend. Furthermore, there is limited information on trends in court outcomes for people with mental disorder who commit homicide.

To examine trends in general population homicide and homicide by people with mental disorder, and to explore court outcome.

We conducted a national, consecutive case series of homicide in England and Wales (1997–2015). Data were received from the Home Office Statistics Unit of Home Office Science. Clinical information was obtained from psychiatric reports and mental health services.

There has been a fall in the homicide rate in England and Wales since 2008. Despite this, the relative contribution of mental disorder as a proportion of all homicide has increased. Our findings also showed the inappropriate management of people with serious mental illness convicted of homicide. Of those who committed homicide and were diagnosed with schizophrenia, a third were imprisoned, and there was a marked fall in hospital order referrals. We found this to be linked to substance misuse comorbidity.

The proportional increase in homicide by people with schizophrenia suggests more complex factors may be driving rates, such as substance misuse. Addressing substance misuse comorbidity and maintaining engagement with services may help prevent patient homicide. Despite their complex needs, people with serious mental illness continue to be imprisoned. Improvements in assessment and the timely transfer of prisoners to health services are required.

Individual- and area-level risk factors for suicide are relatively well-understood but the role of macro social factors such as alienation, social fragmentation or ‘anomie’ is relatively underresearched. Voting choice in the 2016 referendum on the UK's membership of the European Union (EU) provides a potential measure of anomie.

To examine associations between percentage ‘Leave’ votes in the EU referendum and suicide rates in 2015–2017, the period just prior to, and following, the referendum.

National cross-sectional ecological study of 315 English local authority populations. Associations between voting choice in the EU referendum and age-standardised suicide rates, averaged for the years 2015, 2016 and 2017, were examined.

Overall there was a weak, but statistically significant, positive correlation between the local authority-level percentage ‘Leave’ vote in 2016 and the suicide rate 2015–2017: Pearson's correlation coefficient, r = 0.17; P = 0.003. This relationship was explained by populations having an older age distribution, being more deprived and lacking ethnic diversity. However, there was divergence (likelihood ratio test for interaction, χ2 = 7.2, P = 0.007) in the observed associations between London and the provincial regions with Greater London having a moderately strong negative association (r = −0.40; P = 0.02) and the rest of England a weak positive association (r = 0.17; P = 0.004).

Deprivation, older age distribution and a lack of ethnic diversity seems to explain raised suicide risk in Brexit-voting communities. A greater sense of alienation among people feeling ‘left behind’/‘left out’ may have had some influence too, although multilevel modelling of individual- versus area-level data are needed to examine these complex relationships. The incongruent ecological relationship observed for London likely reflect its distinct social, economic and health context.

Worldwide suicide is commonest in young people and in many countries, including the UK, suicide rates in young people are rising.

To investigate the stresses young people face before they take their lives, their contact with services that could be preventative and whether these differ in girls and boys.

We identified a 3-year UK national consecutive case series of deaths by suicide in people aged 10–19, based on national mortality data. We extracted information on the antecedents of suicide from official investigations, primarily inquests.

Between 2014 and 2016, there were 595 suicides by young people, almost 200 per year; 71% were male (n = 425). Suicide rates increased from the mid-teens, most deaths occurred in those aged 17–19 (443, 74%). We obtained data about the antecedents of suicide for 544 (91%). A number of previous and recent stresses were reported including witnessing domestic violence, bullying, self-harm, bereavement (including by suicide) and academic pressures. These experiences were generally more common in girls than boys, whereas drug misuse (odds ratio (OR) = 0.54, 95% CI 0.35–0.83, P = 0.006) and workplace problems (OR 0.52, 95% CI 0.28–0.96, P = 0.04) were less common in girls. A total of 329 (60%) had been in contact with specialist children's services, and this was more common in girls (OR 1.86, 95% CI 1.19–2.94, P = 0.007).

There are several antecedents to suicide in young people, particularly girls, which are important in a multiagency approach to prevention incorporating education, social care, health services and the third sector. Some of these may also have contributed to the recent rise.

It is estimated that 1 in 10 people have a personality disorder. People with emotionally unstable personality disorder are at high risk of suicide. Despite being frequent users of mental health services, there is often no clear pathway for patients to access effective treatments.

To describe the characteristics of patients with personality disorder who died by suicide, examine clinical care pathways and explore whether the care adhered to National Institute for Health and Care Excellence guidance.

National consecutive case series (1 January 2013 to 31 December 2013). The study examined the health records and serious incident reports of patients with personality disorder who died by suicide in the UK.

The majority had a diagnosis of borderline/emotionally unstable or antisocial personality disorder. A high proportion of patients had a history of self-harm (n = 146, 95%) and alcohol (n = 101, 66%) or drug misuse (n = 79, 52%). We found an extensive pattern of service contact in the year before death, with no clear pathway for patients. Care was inconsistent and there were gaps in service provision. In 99 (70%) of the 141 patients with data, the last episode of care followed a crisis. Access to specialised psychological therapies was limited; short-term in-patient admissions was adhered to; however, guidance on short-term prescribing for comorbid conditions was not followed for two-thirds of patients.

Continuity and stability of care is required to prevent, rather than respond to individuals in crisis. A comprehensive audit of services for people with personality disorder across the UK is recommended to assess the quality of care provided.

The 2008 economic recession was associated with an increase in suicide internationally. Studies have focused on the impact in the general population with little consideration of the effect on people with a mental illness.

To investigate suicide trends related to the recession in mental health patients in England.

Using regression models, we studied suicide trends in mental health patients in England before, during and after the recession and examined the demographic and clinical characteristics of the patients. We used data from the National Confidential Inquiry into Suicide and Safety in Mental Health, a national data-set of all suicide deaths in the UK that includes detailed clinical information on those seen by services in the last 12 months before death.

Between 2000 and 2016, there were 21 224 suicide deaths by patients aged 16 or over. For male patients, following a steady fall of 0.5% per quarter before the recession (quarterly percent change (QPC) 2000–2009 –0.46%, 95% CI –0.66 to –0.27), suicide rates showed an upward trend during the recession (QPC 2009–2011 2.37%, 95% CI –0.22 to 5.04). Recession-related rises in suicide were found in men aged 45–54 years, those who were unemployed or had a diagnosis of substance dependence/misuse. Between 2012 and 2016 there was a decrease in suicide in male patients despite an increasing number of patients treated. No significant recession-related trends were found in women.

Recession-associated increases in suicide were seen in male mental health patients as well as the male general population, with those in mid-life at particular risk. Support and targeted interventions for patients with financial difficulties may help reduce the risk at times of economic hardship. Factors such as drug and alcohol misuse also need to be considered. Recent decreases in suicide may be related to an improved economic context or better mental healthcare.

N.K. is supported by Greater Manchester Mental Health NHS Foundation Trust. L.A. chairs the National Suicide Prevention Strategy Advisory Group at the Department of Health (of which N.K. is also a member) and is a non-executive Director for the Care Quality Commission. N.K. chairs the National Institute for Health and Care Excellence (NICE) depression in adults guideline and was a topic expert member for the NICE suicide prevention guideline.