© national confidential inquiry into suicide and homicide by people with mental illness. all rights...
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© National Confidential Inquiry into Suicide and Homicide by People with Mental Illness.All rights reserved. Not to be reproduced in whole or in part
without the permission of the copyright holder.
National Confidential Inquiry into Suicide and Homicide
by People with Mental Illness
How health informatics helps
15th January 2008, ASSIST Meeting
Rebecca Lowe, Administration Manager
Pauline Turnbull, Research Associate
www.manchester.ac.uk/nci
Outline
• Background to Inquiry
• Aims
• Methodology
• Findings
• Limitations
Background
• Set up at University of Manchester in 1996
• Funded by the National Patient Safety Agency
Aims
• To collect detailed clinical information on people who die by suicide or commit homicide and who have been in contact with mental health services
• to make recommendations on clinical practice and policy that will reduce the risk of suicide and homicide by people under mental health care
Suicide Methodology
Obtain national data from the Office for National Statistics
(ONS)
Determine contact with MH services via trust contact
No contact within 12 months
Contact within 12 months
Send questionnaire toconsultant
ONS data
• Received quarterly
• Suicide and open verdict deaths
• Provided with SHA code of residence and death
Trust contacts
• Usually 1 per trust, within Medical Records
• Sent the data for the Strategic Health Authority their Trust covers
• Given a detailed checking protocol
Suicide: Questionnaire
• Demographic features• Diagnostic features• Cause of death• Behavioural features• Contact with services• Priority groups
– in-patients– post-discharge– non-compliance– missed contact
N o previous contact w ithm enta l health services
Send questionnaire to psychia trists
Inquiry case
Previous contact w ith m enta l health servicesidentified by N H S Trusts
Psychia tric reports co llected
N ational sam ple of hom icidesM u rde r, M a ns la u gh ter & In fa n tic ide
Homicide Methodology
Homicide Questionnaire data
• Demographic information
• Psychiatric/Forensic history
• Treatment and compliance
• Views on prevention
• Priority groups include:– in-patient homicides– recently discharged – patients under CPA– missed appointments– non-compliance
Results
Suicide (England/Wales 2000-2004)
• General population suicides: 23,477
• Around 4,500 per year
• Hanging most common method overall
• Self-poisoning most common for females
General population suicide: age and sex profile
0
500
1000
1500
2000
2500
3000
3500
4000
4500
< 25 25-34 35-44 45-54 55-64 65-74 75+
Age groups
Freq
uenc
yMale
Female
Suicide: Inquiry cases
• Inquiry cases: 6,367 (27%)• Questionnaires returned on 6,203 cases (97%) response rate
• 66% male
• 7% ethnic minority
• 69% unmarried, 44% lived alone
• 40% unemployed
• 14% were in-patients at the time of the suicide
• Affective disorder (bipolar disorder & depression) the most common diagnosis (46%)
Method of suicide used by Inquiry cases by sex
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Hanging/strangulation Self-poisoning Carbon monoxidepoisoning
Jumping/multipleinjuries
Drowning Other
Cause of death
Freq
uenc
yMale Female
Homicide (England/Wales 1999-2003)
• General population homicides: 2,670
• Around 500 per year
• 90% Male, median age 28
• Over half of victims were male under 35
• One third killed a family member or
current/ex partner
Method of homicide by sex of perpetrator
0
100
200
300
400
500
600
700
800
900
Sharpinstrument
Bluntinstrument
Hitting orkicking
Strangulation Shooting Other
Freq
uenc
y
Male Female
Homicide: Inquiry cases• Inquiry cases:486 (18%)• Questionnaires returned on 451 cases
(93%) response rate
• 249 seen within the 12 months prior to
homicide
• 87% male
• 71% unmarried, 37% lived alone
• 62% unemployed
• Schizophrenia most common diagnosis
(30%)
Limitations
Missed contact with services
Clinical data based on casenotes and clinical judgements
Completers aware of outcome
The Sudden Unexplained Death Study
Pauline Turnbull
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness
ASSIST PRESTWICH 2008
Outline
• Background
• Methodology
• Results
• Limitations
• Clinical Implications
Background
• Sudden Unexplained Death (SUD)
1. Death by cardiac cause
2. Death within 60 minutes of symptoms
3. NOT a Myocardial Infarction
(World Health Organisation, 1993)
Associations with SUD
• Treatment for mental illness
• Anti-psychotic drug use– Some drugs prolong the QT interval
• Non drug factors– poor physical health
– restraint
Aims of the study
• To determine the number and rate of SUD in psychiatric in-patients in England & Wales
• To examine the circumstances leading up to death
• to conduct a case-control study to identify risk factors for SUD
Methodology
• Data collection began in March 1999
• The SUD study is part of the wider Inquiry
• NPSA funded
• The study is a collaboration between:– The University of Manchester
– The University of Newcastle
– The University of Bristol
Data linked to NACS codes
2 Controls per case
Data collection
HES data
Information from Trusts
Data formatted by SUDS team
Eligibility sent
Non-case
Case
Questionnaire Questionnaire
Data linked to NACS codes
2 Controls per case
Data collection
HES data
Information from Trusts
Data formatted by SUDS team
Eligibility sent
Non-case
Case
Questionnaire Questionnaire
Hospital Episode Statistics (HES)
• NHS number
• Local patient ID
• Sex
• Date of birth
• Date of admission
• Date of discharge
• Mode of discharge
• Consultant GMC code
• Trust code
• Trust site code
Data linked to NACS codes
2 Controls per case
Data collection
HES data
Information from Trusts
Data formatted by SUDS team
Eligibility sent
Non-case
Case
Questionnaire Questionnaire
Data linked to NACS codes
2 Controls per case
Data collection
HES data
Information from Trusts
Data formatted by SUDS team
Eligibility sent
Non-case
Case
Questionnaire Questionnaire
Questionnaire Data
• Demographic information
• Psychiatric history
• Physical health
• Substances taken prior to death
• Last admission
• Circumstances of death
• Additional information
• Questionnaire information is held on an anonymised database
Validation study
• Are we capturing all SUDs?
• Validate all cases and some non-cases
• Clinical Research Fellows:– review case notes
– decide whether patient is a case
– blinded to Consultant Psychiatrist’s opinion
Data linked to NACS codes
2 Controls per case
Data collection
HES data
Information from Trusts
Data formatted by SUDS team
Eligibility sent
Non-case
Case
Questionnaire Questionnaire
Matching Controls
• Controls are matched from HES data – Date of admission same as case– Sex same as case– Date of birth same as case– Alive on the day of death of the case
• Data matched to NACS codes• Questionnaire sent
• Questionnaire information is held on an anonymised database
Results
Age and Sex
0
5
10
15
20
25
30
35
40
45
Fre
qu
ency
<20 20-29 30-39 40-49 50-59 60-69 70-75
Age Group
Male
Female
Physical features
Number (235)
%
(95% CI)
History of Cardiovascular Disease
106
46%
(40 - 53)
History of Respiratory Disease
97
31%
(35 - 48)
Physical examination during final admission
216
93%
(89 - 96)
Clinical featuresNumber
(235) % (95% CI)
Speciality admitted to:
General Adult Psychiatry 97 41% (35 - 48)
Old Age Psychiatry 92 39% (33 - 46)
Primary Diagnosis: Schizophrenia 79 34% (28 - 40)
Affective Disorder 66 28% (23 - 34)
More than 5 previousadmissions 84 37% (30 - 43)
Prescribed Psychotropic Drug 182 78% (72 - 83)
Prescribed two or morePsychotropic drugs
113 49% (42 - 55)
Clinical features
Number(235) % (95% CI)
Patient died on the ward 198 85% (80 - 89)
CPR attempted 126 57% (50 - 64)
Staff trained in CPR 116 87% (80 - 92)
CPR equipment on the ward 131 68% (61 - 75)
Study limitations
• We rely on Consultant Psychiatrists accurately applying SUD criterion
• We may be missing some SUD cases
• Patient records are often missing important information
Clinical Implications
• QT prolonging medication should be used with caution
• Physical health care is important– assess physical health on admission
– follow up evidence of poor physical health
– include physical health care in care plan
– training opportunities for mental health nurses in physical health care
• CPR equipment and CPR trained staff could be more accessible
Contact Details
The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness
Centre for Suicide Prevention
The University of Manchester
Williamson Building
Oxford Road, Manchester
M13 9PL, UK
Telephone: (+44) 161-275-0700
Email: rebecca.lowe@manchester.ac.uk pauline.turnbull@manchester.ac.uk
http://www.medicine.manchester.ac.uk/suicideprevention/
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