Suicide in primary care: findings of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness was established in its current form at Manchester University in 1996. From 1991, prior to the move to Manchester, research in this area had been managed within the Royal College of Psychiatrists.

The NCISH has established an outstanding national and international reputation for the quality of its research. It uses a range of methodologies such as case-control studies, psychological autopsy and data linkage along with access to other large health data sets, such as practice lists, to explore the difficult and troubling subjects of suicide and homicide. The NCISH has produced a series of reports which are aimed at learning the lessons from these terrible personal tragedies and improving practice across mental health and related services.

The unit’s previous report highlighted the fact that though the number of homicides by people with mental health problems had fallen, the number of suicides in this group has actually risen. A rise in suicides is associated with a period of economic austerity where people face increased financial and social pressures, but there are reductions in public health and general welfare provisions.

Download the full NCISH report

Methods

Last month saw the publication of the new NCISH report into suicide in primary care in England. The research team used the Clinical Practice Research Datalink (a database that holds over 5 million electronic patient records) and Office of National Statistics (ONS) data.

The research looked at 2,384 patients who died by suicide over a 10 year period (2002-2011). These patients were matched with 46,899 living patients with similar characteristics such as age, gender and GP practice. Thus there were up to 20 control patients for each patient who died by suicide. All the patients who had died by suicide where over 16 years of age. Through this case matching, the researchers examined:

Frequency and patterns of GP consultations
Diagnosis of mental illness
Prescription of psychotropic drugs
Referral to specialist mental health services

The report confirms that middle-aged men are a high risk group for suicide

Results

76% of patients who died by suicide were male – the median age was 45. This finding supports other suicide research that highlights middle-aged men as being a high risk group

The study examined how often the patients had been to see their GP in the year prior to the suicide:
- 63% had done so but there was significant variation in the number of appointments (between 1 and 24)
- 37% of this group had not been to see their GP in the previous 12 months. This group was more likely to include male patients, but also younger men and women
- The non-attenders were also less likely to have a mental health diagnosis

The majority of the group 1,497 (or 63%) who died by suicide had a mental health diagnosis
- The most common diagnosis was depression, but only 8% had been referred to mental health services in the previous 12 months

The study also examined the patterns of prescribing. It concluded that patients who died by suicide were:

Five times more likely to be on psychotropic drugs, five times more likely to be on antipsychotic drugs and seven times more likely to be on antidepressants.

Being prescribed more than one type of drug was associated with an 11-fold increase in suicide risk

Conclusions

The report has some very important messages for primary care, which it should be remembered is the focus of most mental health provision.

The study indicates that mental illness amongst those who eventually die by suicide is frequently unrecognised in primary care. The current pressures on such services might increase these risks.

However, there is also an issue here about outreach working and encouraging individuals to seek support. As the report notes, non-attendance is an indicator of increased risk. This is a much wider public health issue as this pattern can be seen in other areas of health care for the groups that are most at risk – young males in particular. This is an area where the voluntary sector and other agencies such as colleges, community groups have a key role to play.

The short-sighted nature of the austerity policies means that the pressures on these services means that they are struggling to meet demands, just when their services are needed most.