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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.
To explore the portrayal of homicide-suicide in newspaper articles, particularly how mental illness was reported. We carried out a qualitative study in England and Wales (2006–2008). Data from newspaper articles obtained via the LexisNexis database were used to examine a consecutive series of 60 cases.
A fascination with extreme violence, vulnerable victims and having someone to blame made homicide-suicides newsworthy. Some offenders were portrayed in a stereotypical manner and pejorative language was used to describe mental illness. The findings showed evidence of inaccurate and speculative reference to mental disorder in newspaper reports.
The media should avoid speculation on people's mental state. Accurate reporting is essential to reduce stigma of mental illness, which may in turn encourage people to seek help if they experience similar emotional distress.
The rise in homicides by those with serious mental illness is of concern,
although this increase may not be continuing.
To examine rates of mental illness among homicide perpetrators.
A national consecutive case series of homicide perpetrators in England
and Wales from 1997 to 2006. Rates of mental disorder were based on data
from psychiatric reports, contact with psychiatric services, diminished
responsibility verdict and hospital disposal.
Of the 5884 homicides notified to the National Confidential Inquiry into
Suicide and Homicide by People with Mental Illness between 1997 and 2006,
the number of homicide perpetrators with schizophrenia increased at a
rate of 4% per year, those with psychotic symptoms at the time of the
offence increased by 6% per year. The number of verdicts of diminished
responsibility decreased but no change was found in the number of
perpetrators receiving a hospital order disposal. The likeliest
explanation for the rise in homicide by people with psychosis is the
misuse of drugs and/or alcohol, which our data show increased at a
similar magnitude to homicides by those with psychotic symptoms. However,
we are unable to demonstrate a causal association. Although the Poisson
regression provides evidence of an upward trend in homicide by people
with serious mental illness between 1997 and 2006, the number of
homicides fell in the final 2 years of data collection, so these findings
should be treated with caution.
There appears to be a concomitant increase in drug misuse over the
period, which may account for this rise in homicide. However, an increase
in the number of people in contact with mental health services may
suggest that access to mental health services is improving. Previous
studies have used court verdicts such as diminished responsibility as a
proxy measure of mental disorder. Our data indicate that this does not
reflect accurately the prevalence of mental disorder in this
Suicide prevention is a health service priority. Suicide risk may be
greatest during psychiatric in-patient admission and following
To describe the social and clinical characteristics of a comprehensive
sample of in-patient and post-discharge cases of suicide.
A national clinical survey based on a 4-year (1996–2000) sample of cases
of suicide in England and Wales who had been in recent contact with
mental health services (n=4859).
There were 754 (16%) current in-patients and a further 1100 (23%) had
been discharged from psychiatric in-patient care less than 3 months
before death. Nearly a quarter of the in-patient deaths occurred within
the first 7 days of admission; 236 (31%) occurred on the ward, the
majority by hanging. Post-discharge suicide was most frequent in the
first 2 weeks after leaving hospital; the highest number occurred on the
Suicide might be prevented among in-patients by improving ward design and
removing fixtures that can be used in hanging. Prevention of suicide
after discharge requires early community follow-up and closer supervision
of high-risk patients.
Suicide prevention is a health service priority but the most effective
approaches to prevention may differ between different patient groups.
To describe social and clinical characteristics in cases of suicide from
different age and diagnostic groups.
A national clinical survey of a 4-year (1996–2000) sample of cases of
suicide in England and Wales where there had been recent (< 1 year)
contact with mental health services (n=4859).
Deaths of young patients were characterised by jumping from a height or
in front of a vehicle, schizophrenia, personality disorder, unemployment
and substance misuse. In older patients, drowning, depression, living
alone, physical illness, recent bereavement and suicide pacts were more
common. People with schizophrenia were often in-patients and died by
violent means. About athird of people with depressive disorder died
within a year of illness onset. Those with substance dependence or
personality disorder had high rates of disengagement from services.
Prevention measures likely to benefit young people include targeting
schizophrenia, dual diagnosis and loss of service contact; those aimed at
depression, isolation and physical ill-health should have more effect on
Previous studies of people convicted of homicide have used different
definitions of mental disorder.
To estimate the rate of mental disorder in people convicted of homicide;
to examine the relationship between definitions, verdict and outcome in
A national clinical survey of people convicted of homicide
(n=1594) in England and Wales (1996–1999). Rates of
mental disorder were estimated based on: lifetime diagnosis, mental
illness at the time of the offence, contact with psychiatric services,
diminished responsibility verdict and hospital disposal.
Of the 1594, 545 (34%) had a mental disorder: most had not attended
psychiatric services; 85 (5%) had schizophrenia (lifetime); 164 (10%) had
symptoms of mental illness at the time of the offence; 149 (9%) received
a diminished responsibility verdict and 111 (7%) a hospital disposal –
both were associated with severe mental illness and symptoms of
The findings suggest an association between schizophrenia and conviction
for homicide. Most perpetrators with a history of mental disorder were
not acutely ill or under mental healthcare at the time of the offence.
Some perpetrators receive prison sentences despite having severe mental
Information on suicide by psychiatric patients from ethnic minority groups is scarce.
To establish the number of patients from ethnic minorities who kill themselves; to describe their suicide methods, and their social and clinical characteristics.
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.
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.
In order to reduce the number of suicides byethnicminority patients, services should address the complex health and social needs of people with severe mental illness.
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