The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness was established in 1992. Since its relocation to Manchester in 1996 the Inquiry has collected information on 11 673 people who were in contact with mental health services in the year before their suicide and 743 perpetrators of homicide who were in contact with mental health services before their offence. In 2003, the Sudden Unexplained Death in Psychiatric In-Patients’ Study, which has collected data on patients dying on mental health wards since 1999, was incorporated into the core work programme of the Inquiry. The Inquiry has published several reports (Appleby et al, 1999, 2001) and papers (see the National Confidential Inquiry website at http://www.medicine.manchester.ac.uk/suicideprevention/nci/). Key findings are outlined in Box 1. Recommendations made have been incorporated into policy planning and service development, including the National Service Framework for Mental Health (Department of Health, 1999a), An Organisation with a Memory (Department of Health, 2000a), The NHS Plan (Department of Health, 2000b) and the National Suicide Prevention Strategy for England (Department of Health, 2002).
The Inquiry collects data throughout the UK on all people with a history of contact with mental health services who die by suicide or commit homicide. The questionnaires issued by the Inquiry are regularly reviewed and modified in response to feedback from mental health teams. Questionnaires are comprehensive, collecting data on sociodemographic characteristics, clinical history, aspects of clinical care, details of final service contact, details of the suicide or homicide itself and the respondent’s views on risk reduction and prevention.
The Inquiry recommends measures by which services might reduce the risk of such adverse incidents (http://www.medicine.manchester.ac.uk/suicideprevention/nci) and has recently embarked on a series of new studies.
Box 1. Key findings regarding suicide and homicide by people with mental illness
4500-5000 general population suicides occur per year in England and Wales, approximately 25% of these people have been in recent contact with mental health services
160-200 psychiatric in-patients die by suicide annually, most commonly by hanging; this figure has fallen during the past decade
The period of highest risk after discharge from in-patient care is the first 14 days
Over one-fifth of individuals dying by suicide have not been adherent to medication in the preceding month and nearly one-third have disengaged from services.
Around 50 homicides per year are committed by those in recent contact with mental health services; this represents 9% of all homicides
5% of homicide perpetrators have a diagnosis of schizophrenia
Perpetrators with mental illness are less likely to kill strangers and the rate of ‘stranger homicides’ by those with mental illness has not increased with national trends
Alcohol and drug misuse contribute to homicide in 61% of cases: this clearly has major public health implications.
Previous criticisms of the Inquiry recommendations include the lack of conclusive evidence from intervention studies demonstrating their efficacy. For example, the recommendation to improve the overall quality of care and supervision to many patients, so that they would not go on to die by suicide or commit homicide, has been described as a waste of resources (Geddes, 1999). The Inquiry is addressing the lack of evidence-based interventions by carrying out a longitudinal study monitoring changes in suicide rates in trusts and their relationship to changes in service provision.
Another methodological limitation is that the Inquiry data are based on clinicians’ retrospective examination of case records and their judgement. We are therefore expanding data collection on both suicide and homicide using psychological autopsy methodologies to include both quantitative and descriptive information from a wide range of sources.
Another recommendation made to the Inquiry was to expand data collection to include ‘near misses’. The Inquiry has commenced a study examining the care of people in contact with mental health services who are convicted of serious violent offences. Finally, in order to address a further criticism that there have been no control data the Inquiry has commenced two national case-control studies on high-risk patients, which should allow aetiological conclusions to be drawn about suicide in certain priority groups.
Serious violence by people with mental illness
Epidemiological studies have established a small but significant association between serious mental illness, particularly schizophrenia, and violence (Brennan et al, 2000). However, there have been no large-scale studies examining the frequency and nature of contact with mental health services prior to a serious violent offence.
The Inquiry’s remit is being extended to obtain data on mental health service contact of those convicted of serious violence. Serious violence includes attempted murder, threat or conspiracy to murder, and other acts of endangering life and malicious wounding. The aim is to establish the prevalence of contact with mental health services in individuals convicted of these offences, and to examine their social and clinical characteristics and mental healthcare in order to inform practice.
Psychological autopsy study of suicides
Pioneered by Robins et al in 1959, the psychological autopsy has been an accepted method for investigating the psychosocial characteristics of suicide victims for decades (Robins et al, 1959; Barraclough et al, 1974). It has been described as ‘probably the most direct technique currently available for determining the relationship between particular risk factors and suicide’ (Hawton et al, 1998).
Psychological autopsy studies involve collecting detailed information from a number of different sources, including relatives of the deceased, general practitioners, and accident and emergency departments.
Despite the fact that the majority of people who die by suicide in the general population having a definable mental illness at the time of death (Barraclough et al, 1974), only a quarter have been in contact with mental health services in the year prior to death (Appleby et al, 2001). This raises important questions regarding key differences between those with and without contact with services and regarding accessibility of services themselves. The National Inquiry study, of 250 consecutive suicides in north-west England from 1 January 2003, extends data collection on suicides in contact with mental health services to include information from coroners, relatives, general practitioners and emergency departments and allows a fuller investigation of the preventable antecedents of suicide. It will, therefore, provide important insights into service provision for those in contact with services and, given the sample size of 250, will allow us to look at subgroups such as in-patients and patients post-discharge.
The study will also provide an opportunity to examine the feasibility of gathering data from additional sources, including primary care, and therefore on suicides among the general population.
Antecedents of homicide study
Despite suggestions that the psychological autopsy methodology might provide a greater understanding of homicide from a victim and perpetrator perspective (Allen, 1981), no such study has yet been carried out.
The Inquiry is currently conducting a pilot study to examine the feasibility of using this methodology to study homicide, specifically rates of mental disorder in perpetrators of homicide and the relationship between criminological and clinical antecedents to homicide. We are gathering data on a consecutive sample of 25 homicides in Greater Manchester from multiple sources including the perpetrators themselves, their relatives, primary care, emergency departments and police forces. If feasible, this study will then be conducted on a larger sample.
Case-control studies of suicides by in-patients and within 3 months of discharge
The Inquiry is essentially a descriptive study and although uncontrolled national studies can be informative for service planning, no aetiological conclusions can be drawn.
The Inquiry has recently completed case-control studies in two high-risk groups who die by suicide: psychiatric in-patients and former in-patients within 3 months of discharge. These suicides are by patients in close proximity to services and are therefore potentially amenable to preventative strategies by mental health services. We aim to quantify the risk associated with key risk factors and guide services on improving safety at time of high risk. The findings will be submitted for publication shortly.
Service monitoring study
A quarter of people who die by suicide have had contact with specialist mental health services in the year before their death (Appleby et al, 2001). The UK White Paper Saving Lives: Our Healthier Nation targeted a 20% reduction in the suicide rate among the general population from 1997 to 2010 (Department of Health, 1999b). Although suicide prevention is an NHS priority, the efficacy of different interventions in reducing the rate of suicide is, as yet, unknown. No interventions to date have reliably been shown to prevent suicide (Geddes, 1999).
Previous Inquiry reports have included recommendations for improving services with the aim of reducing the likelihood of suicide (Appleby et al, 1999, 2001). Local mental health services are being supported by the National Institute for Mental Health in England in the implementation of these recommendations.
The service monitoring study of the National Inquiry aims to establish the extent to which mental health trusts have implemented Inquiry recommendations, and to subsequently establish the association between implementing recommendations and changes in suicide rates.
The Inquiry represents a unique opportunity to collect detailed information about suicides, homicides and serious violence by people with mental illness, but its goals can only be attained if clinicians provide the required information. It is clear that we will be asking more of clinicians, given the new studies that we are embarking on. Ongoing cooperation and continued assistance of clinicians in further developing our understanding of adverse incidents in the psychiatric population will be invaluable. Furthermore, widening our process of data collection to include relatives, coroners, general practitioners and emergency departments may result in higher refusal rates and, in the antecedents of homicide study, potential problems in acquiring patient consent. So far, however, responses have been encouraging.
Confidentiality of data submitted to the Inquiry is maintained at all times. All Inquiry studies are registered under the Data Protection Act 1998 and have received section 60 approval from the Patient Information Advisory Group. All data are aggregated for analysis and no individual cases are reported. Because we gather information after conviction in the case of homicide, anxieties about disclosure in relation to the legal process should have subsided.
Suicide, homicide and serious violence by people with mental illness in contact with mental health services are sensitive issues, but the aim of the Inquiry nearly a decade on remains the same: to improve services, not to blame them.
- © 2007 Royal College of Psychiatrists