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IntroductionPatients being discharged from inpatient mental wards often describe safety risks in terms of inadequate information sharing and involvement in discharge decisions. Through stakeholder engagement, we co-designed, developed and adapted two versions of a care bundle intervention, the SAFER Mental Health care bundle for adult and youth inpatient mental health settings (SAFER-MH and SAFER-YMH, respectively), that look to address these concerns through the introduction of new or improved processes of care.Methods and analysisTwo uncontrolled before-and-after feasibility studies, where all participants will receive the intervention. We will examine the feasibility and acceptability of the SAFER-MH in inpatient mental health settings in patients aged 18 years or older who are being discharged and the feasibility and acceptability of the SAFER-YMH intervention in inpatient mental health settings in patients aged between 14 and 18 years who are being discharged. The baseline period and intervention periods are both 6 weeks. SAFER-MH will be implemented in three wards and SAFER-YMH in one or two wards, ideally across different trusts within England. We will use quantitative (eg, questionnaires, completion forms) and qualitative (eg, interviews, process evaluation) methods to assess the acceptability and feasibility of the two versions of the intervention. The findings will inform whether a main effectiveness trial is feasible and, if so, how it should be designed, and how many patients/wards should be included.Ethics and disseminationEthical approval was obtained from the National Health Service Cornwall and Plymouth Research Ethics Committee and Surrey Research Ethics Committee (reference: 22/SW/0096 and 22/LO/0404). Research findings will be disseminated with participating sites and shared in various ways to engage different audiences. We will present findings at international and national conferences, and publish in open-access, peer-reviewed journals.

Made available in DSpace on 2022-04-28T19:40:08Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-07-01 Background: The COVID-19 pandemic is having profound mental health consequences for many people. Concerns have been expressed that, at their most extreme, these consequences could manifest as increased suicide rates. We aimed to assess the early effect of the COVID-19 pandemic on suicide rates around the world. Methods: We sourced real-time suicide data from countries or areas within countries through a systematic internet search and recourse to our networks and the published literature. Between Sept 1 and Nov 1, 2020, we searched the official websites of these countries’ ministries of health, police agencies, and government-run statistics agencies or equivalents, using the translated search terms “suicide” and “cause of death”, before broadening the search in an attempt to identify data through other public sources. Data were included from a given country or area if they came from an official government source and were available at a monthly level from at least Jan 1, 2019, to July 31, 2020. Our internet searches were restricted to countries with more than 3 million residents for pragmatic reasons, but we relaxed this rule for countries identified through the literature and our networks. Areas within countries could also be included with populations of less than 3 million. We used an interrupted time-series analysis to model the trend in monthly suicides before COVID-19 (from at least Jan 1, 2019, to March 31, 2020) in each country or area within a country, comparing the expected number of suicides derived from the model with the observed number of suicides in the early months of the pandemic (from April 1 to July 31, 2020, in the primary analysis). Findings: We sourced data from 21 countries (16 high-income and five upper-middle-income countries), including whole-country data in ten countries and data for various areas in 11 countries). Rate ratios (RRs) and 95% CIs based on the observed versus expected numbers of suicides showed no evidence of a significant increase in risk of suicide since the pandemic began in any country or area. There was statistical evidence of a decrease in suicide compared with the expected number in 12 countries or areas: New South Wales, Australia (RR 0·81 [95% CI 0·72–0·91]); Alberta, Canada (0·80 [0·68–0·93]); British Columbia, Canada (0·76 [0·66–0·87]); Chile (0·85 [0·78–0·94]); Leipzig, Germany (0·49 [0·32–0·74]); Japan (0·94 [0·91–0·96]); New Zealand (0·79 [0·68–0·91]); South Korea (0·94 [0·92–0·97]); California, USA (0·90 [0·85–0·95]); Illinois (Cook County), USA (0·79 [0·67–0·93]); Texas (four counties), USA (0·82 [0·68–0·98]); and Ecuador (0·74 [0·67–0·82]). Interpretation: This is the first study to examine suicides occurring in the context of the COVID-19 pandemic in multiple countries. In high-income and upper-middle-income countries, suicide numbers have remained largely unchanged or declined in the early months of the pandemic compared with the expected levels based on the pre-pandemic period. We need to remain vigilant and be poised to respond if the situation changes as the longer-term mental health and economic effects of the pandemic unfold. Funding: None. Centre for Mental Health Melbourne School of Population and Global Health University of Melbourne Swansea University Medical School Translational Health Research Institute Western Sydney University Ministry of Public Health Department of Health Promotion National Confidential Inquiry into Suicide and Safety in Mental Health University of Manchester Centre for Mental Health and Safety and National Institute for Health Research Patient Safety Translational Research Centre University of Manchester School of Public Health National Suicide Research Foundation University College Cork Australian Institute for Suicide Research and Prevention School of Applied Psychology Griffith University Institute for Life Course Health Research Department of Global Health Stellenbosch University Working Group on Prevention of Suicide and Depression at Public Health Council Department of Psychiatry Blekinge Hospital Botucatu Medical School Universidade Estadual Paulista Instituto Nacional de Psiquiatría Ramon de la Fuente Muñiz University of Rochester Medical Center Region Friuli Venezia Giulia Central Health Directorate Outpatient and Inpatient Care Service Department of Medicine University of Udine Institute of Health Behaviors and Community Sciences College of Public Health National Taiwan University Thames Valley Local Criminal Justice Board Department of Psychiatry Psychotherapy and Psychosomatics Medical University of Innsbruck Center for Outcomes Research and Evaluation Yale School of Medicine Coroners Court of Victoria Danish Research Institute for Suicide Prevention Department of Mental Health Johns Hopkins School of Public Health Centre for Mental Health Research Australian National University Brigham and Women's Hospital Department of Emergency Medicine School of Population Health University of Auckland Magistrates Court of Tasmania (Coronial Division) Bureau of Vital Records and Statistics Louisiana Office of Public Health Ministry of Public Health Undersecretary of Health Services Research Department, 113 Suicide Prevention Departments of Psychiatry and Epidemiology Columbia University Medical Center/New York State Psychiatric Institute Centre for Suicide Research University of Oxford Louisiana Department of Health Greater Manchester Mental Health NHS Foundation Trust Department of Psychiatry Aga Khan University KU Leuven Center for Contextual Psychiatry Population Health Sciences Bristol Medical School University of Bristol South Asian Clinical Toxicology Research Collaboration Faculty of Medicine University of Peradeniya World Health Organization Country Office for Nepal Karolinska Institutet Bekhterev National Medical Research Center of Psychiatry and Neurology Pavlov First Saint Petersburg State Medical University Unit Suicide Research and Mental Health Promotion Department of Social and Preventive Medicine Center for Public Health Medical University of Vienna Department of Child and Adolescent Psychiatry Medical University of Vienna School of Psychology University of Nottingham Self-Harm Research Group School of Psychology University of Nottingham Mental Health Centre Copenhagen Department of Psychiatry and Psychotherapy Klinikum Klagenfurt am Wörthersee Suicidal Behaviour Research Lab University of Glasgow Preventing Deaths from Poisoning Research Group University of Edinburgh Usher Institute University of Edinburgh Suicide Research and Prevention Center Shanghai Mental Health Center Shanghai Jiao Tong University School of Medicine Departments of Psychiatry and Epidemiology Columbia University Department of Child and Adolescent Psychiatry and Psychotherapy University of Ulm Psychosocial Services in Vienna National Centre for Suicide Research and Prevention Institute of Clinical Medicine University of Oslo Department of Child and Adolescent Psychiatry Psychotherapy and Psychosomatics University Hospital Leipzig Department of Psychiatry and Psychotherapeutic Medicine Landeskrankenhaus Villach Department of Psychiatry Psychosomatic Medicine and Psychotherapy University Hospital Frankfurt Department of Borderline Disorders and Psychotherapy Bekhterev National Medical Research Center of Psychiatry and Neurology Saint Petersburg State University Department of Psychiatry Health Authority Frankfurt am Main Department of Addictive Disorders Psychiatry and Psychotherapy LVR-Klinik Köln Department of Psychiatry Psychosomatic Medicine and Psychotherapy Goethe-University Organizational-Scientific Department Bekhterev National Medical Research Center of Psychiatry and Neurology Department of Psychiatry University of Toronto Department of Psychiatry Sunnybrook Health Sciences Centre Waseda University Faculty of Political Science and Economics Sneha—Suicide Prevention Centre Voluntary Health Services Department of Community Medicine Faculty of Medicine and Allied Sciences Rajarata University of Sri Lanka Department of Psychiatry Sackler School of Medicine Tel Aviv University and Geha Mental Health Center Division of Molecular Imaging and Neuropathology New York State Psychiatric Institute and Department of Psychiatry Columbia University National Institute of Health Research Biomedical Research Centre University Hospitals Bristol and Weston NHS Foundation Trust University of Bristol Department for Psychiatry University Psychiatric Hospital Vrapče School of Medicine University of Zagreb Botucatu Medical School Universidade Estadual Paulista

In ever more pressured health-care systems, technological solutions offering scalability of care and better resource targeting are appealing. Research on machine learning as a technique for identifying individuals at risk of suicidal ideation, suicide attempts, and death has grown rapidly. This research often places great emphasis on the promise of machine learning for preventing suicide, but overlooks the practical, clinical implementation issues that might preclude delivering on such a promise. In this Review, we synthesise the broad empirical and review literature on electronic health record-based machine learning in suicide research, and focus on matters of crucial importance for implementation of machine learning in clinical practice. The challenge of preventing statistically rare outcomes is well known; progress requires tackling data quality, transparency, and ethical issues. In the future, machine learning models might be explored as methods to enable targeting of interventions to specific individuals depending upon their level of need-ie, for precision medicine. Primarily, however, the promise of machine learning for suicide prevention is limited by the scarcity of high-quality scalable interventions available to individuals identified by machine learning as being at risk of suicide. ispartof: LANCET PSYCHIATRY vol:9 issue:3 pages:243-252 ispartof: location:England status: published

Background National guidelines for the short-term management of self-harm are aimed at healthcare professionals who may be involved in the care of people who have self-harmed. However, evidence from small-scale studies globally suggest there is a lack of awareness of such guidelines among some groups of healthcare professionals. For the first time in a large representative sample of patient-facing healthcare professionals, we aimed to identify: (a) which healthcare professionals are aware of guidelines for the management of self-harm; (b) the perceived availability of training; (c) the use of risk screening tools; and (d) the extent to which healthcare professionals implement guidelines for the management of self-harm. Methods 1020 UK healthcare professionals completed a cross-sectional survey online. Results 85.6% (873/1020) of the sample had heard of the national guidelines, but only 24.3% (248/1020) knew “a fair amount” or more about them. Of the respondents who had previously encountered a patient who had self-harmed or was at risk of repeat self-harm, the guidelines were implemented in fewer than 50% (M = 43.89%, SD = 38.79) of encounters. 31% (312/1020) of the sample had received training in managing self-harm and, contrary to guidelines, 2.25% (23/1020) of the sample had used self-harm risk screening tools. Conclusions Our findings highlight a need to improve knowledge of self-harm management guidelines, and identifies professional groups where awareness and knowledge is currently low. Further work is required to develop interventions to change healthcare professional practice with respect to the implementation of self-harm management guidelines., Highlights • 85.6% of healthcare professionals have heard of the NICE guidelines for self-harm. • 24.3% of healthcare professionals know what is in the guidelines for self-harm. • 2.3% of healthcare professionals breach ‘do not do’ recommendations. • Guidelines for self-harm are implemented in 43.9% of encounters with patients. • Awareness of self-harm guidelines was lowest outside mental health settings.

Parricide is a rare type of homicide in which mental illness is often an important factor. The aims of this study were (a) to describe the characteristics of parricide offenders with a focus on mental illness and clinical care and (b) to examine Heide's widely used typology of parricide through a data-driven approach. We analyzed all homicides in England and Wales between 1997 and 2014. Parricide offenders in our sample were most often male, unmarried, and unemployed, with a third of offenders diagnosed with schizophrenia; 28% had been in contact with mental health services before the offense. The latent class analysis resulted in three types of parricide offenders: middle-aged with affective disorder, previously abused, and seriously mentally Ill, which confirmed, to an extent, Heide's typology. Health and social care services should actively engage with carers of people with mental illness and support to those caring for older relatives and victims of abuse.

BackgroundExisting evidence suggests that some individuals from ethnic minority backgrounds are at increased risk of suicide compared to their majority ethnic counterparts, whereas others are at decreased risk. We aimed to estimate the absolute and relative risk of suicide in individuals from ethnic minority backgrounds globally.MethodsDatabases (Medline, Embase, and PsycInfo) were searched for epidemiological studies between 01/01/2000 and 3/07/2020, which provided data on absolute and relative rates of suicide amongst ethnic minority groups. Studies reporting on clinical or specific populations were excluded. Pairs of reviewers independently screened titles, abstracts, and full texts. We used random effects meta-analysis to estimate overall, sex, location, migrant status, and ancestral origin, stratified pooled estimates for absolute and rate ratios. PROSPERO registration: CRD42020197940.FindingsA total of 128 studies were included with 6,026,103 suicide deaths in individuals from an ethnic minority background across 31 countries. Using data from 42 moderate-high quality studies, we estimated a pooled suicide rate of 12·1 per 100,000 (95% CIs 8·4–17·6) in people from ethnic minority backgrounds with a broad range of estimates (1·2–139·7 per 100,000). There was weak statistical evidence from 51 moderate-high quality studies that individuals from ethnic minority groups were more likely to die by suicide (RR 1·3 95% CIs 0·9–1·7) with again a broad range amongst studies (RR 0·2–18·5). In our sub-group analysis we only found evidence of elevated risk for indigenous populations (RR: 2·8 95% CIs 1·9–4·0; pooled rate: 23·2 per 100,000 95% CIs 14·7–36·6). There was very substantial heterogeneity (I2 > 98%) between studies for all pooled estimates.InterpretationThe homogeneous grouping of individuals from ethnic minority backgrounds is inappropriate. To support suicide prevention in marginalised groups, further exploration of important contextual differences in risk is required. It is possible that some ethnic minority groups (for example those from indigenous backgrounds) have higher rates of suicide than majority populations.FundingNo specific funding was provided to conduct this research. DK is funded by Wellcome Trust and Elizabeth Blackwell Institute Bristol. Matthew Spittal is a recipient of an Australian Research Council Future Fellowship (project number FT180100075) funded by the Australian Government. Rebecca Musgrove is funded by the NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC-2016-003).

Background Suicide has profound effects on families and communities, but is a statistically rare event. Psychological autopsies using a case-control design allow researchers to examine risk factors for suicide, using a variety of sources to detail the psychological and social characteristics of decedents and to compare them to controls. The Suicide Support and Information System Case Control study (SSIS-ACE) aimed to compare psychosocial, psychiatric and work-related risk factors across three groups of subjects: suicide decedents, patients presenting to hospital with a high-risk self-harm episode, and general practice controls. Methods The study design includes two inter-related studies; one main case-control study: comparing suicide cases to general practice (GP) controls, and one comparative study: comparing suicide cases to patients presenting with high-risk self-harm. Consecutive cases of suicide and probable suicide are identified through coroners’ registration of deaths in the defined region (Cork City and County, Ireland) and are frequency-matched for age group and gender with GP patient controls recruited from the same GP practice as the deceased. Data sources for suicide cases include coroners’ records, interviews with health care professionals and proxy informants; data sources for GP controls and for high-risk self-harm controls include interviews with control, with proxy informants and with health care professionals. Interviews are semi-structured and consist of quantitative and qualitative parts. The quantitative parts include a range of validated questionnaires addressing psychiatric, psychosocial and occupational factors. The study adopts several methodological innovations, including accessing multiple data sources for suicide cases and controls simultaneously, recruiting proxy informants to examine consistency across sources. Conclusions The study allows for the investigation of consistency across different data sources and contributes to the methodological advancement of psychological autopsy research. The study will also inform clinical and public health practice. The comparison between suicide cases and controls will allow investigation of risk and protective factors for suicide more generally, while the comparison with high-risk self-harm patients will help to identify the factors associated specifically with a fatal outcome to a self-harm episode. A further enhancement is the particular focus on specific work-related risk factors for suicide.

Background: While some people who have had COVID-19 experience fatigue and sleep problems long after the acute phase of the illness, the proportion affected and the length of time symptoms persist remains uncertain. There are also concerns of an increase in psychiatric illness following COVID-19 infection; however evidence of a direct effect is inconclusive. Methods: This was a retrospective cohort study using a UK primary care registry. Adults with a positive PCR COVID-19 test between 1st February and 8th December 2020 were matched to controls based on gender, general practice and year of birth. Separate matched cohorts were assembled for those with and without prior recorded mental illness, fatigue and sleep problems. Cox proportional hazard models estimated the association between a COVID-19 positive test and subsequent psychiatric morbidity (depression, anxiety, psychosis, or self-harm), sleep problems, fatigue or psychotropic prescribing, adjusted for comorbidities, ethnicity, smoking status and BMI. Interaction with age and area-level deprivation were tested for. Additional cohorts examined those with a negative COVID-19 test and those with influenza symptoms (and a negative COVID-19 test). Results: After adjusting for observed confounders, there was an association between testing positive for COVID-19 (n=232,780) and almost all markers of psychiatric morbidity, psychotropic prescribing, fatigue and sleep problems. The adjusted hazard ratio for any indicator of incident psychiatric morbidity was 1.75 (95% CI: 1.56-1.96) and for new psychotropic prescribing 2.17 (95% CI: 2.00-2.35). However, there was an increased risk of incident psychiatric morbidity for those with a negative COVID-19 test of similar magnitude and a larger increase associated with having influenza. Interpretation: Whilst COVID-19 infection appears to be causing sleep problems and fatigue, there is less clear evidence of an effect on subsequent psychiatric morbidity. Funding Information: This work was funded by the NIHR Greater Manchester Patient Safety Translational Research Centre. Declaration of Interests: TC received ad hoc payments for conducting workshops on evidence-based treatments for persistent physical symptoms. TC has received grants from NIHR programme grants, HTA, RfPB, Guy’s and St Thomas Charity, King’s Challenge Fund. Personal financial interests: TC is the author of several self-help books on chronic fatigue and received royalties in the past. TC received expenses for workshops on evidence-based treatments for persistent physical symptoms for BABCP and IAPT services (travel and accommodation). None of the other authors have any conflicts of interest. Ethics Approval Statement: This study was conducted using data from the CPRD obtained under licence from the UK Medicines and Healthcare products Regulatory Agency (MHRA). The data are provided by patients and collected by the NHS as part of their care and support. The study was approved by the Independent Scientific Advisory Committee for CPRD research (20_094R2).

Background: There are concerns that the COVID-19 pandemic may lead to an increase in suicide. The coronial system in England is not suitable for close monitoring of suicide because of the frequent gap of several months before inquests are held. Methods: We used data from established systems of "real time surveillance" (RTS) of suspected suicides, in areas covering a total population of around 13 million, to examine for any increase after the first national lockdown in England. Outcomes: The average monthly number of suicides in the months before lockdown, January-March 2020, was 125·7, compared to 121·3 in April-October 2020 (-4%; 95% CI -19% to 13%, p=0·59). Incidence rate ratios did not rise significantly in individual months after lockdown began and were not raised during the 2-month lockdown period April-May 2020 or the 5-month period after the easing of lockdown, June-October 2020 (IRR: 1·00 [0·8-1·25] and 0·94 [0·81-1·08]). Comparison of the suicide rates after lockdown in 2020 for the same months in selected areas in 2019 showed no difference. Interpretation: We did not find a rise in suicide in England in the months after the first national lockdown began in 2020, despite evidence of greater distress. However, a number of caveats should be noted. These are early figures and may change. Any effect of the pandemic may vary by population group or geographical area. The use of RTS in this way is new and further development is needed before it can provide full national data. Funding: The study was carried out as part of the role of the National Confidential Inquiry into Suicide and Safety in Mental Health in supporting suicide prevention in England, funded by NHS England/NHS Improvement. Declaration of Interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: LA chairs the National Suicide Prevention Strategy Advisory Group (NSPSAG) at the Department of Health and Social Care in England; NK is a member of the Group, chaired the guideline development group for the 2012 National Institute for Health and Clinical Excellence (NICE) guidelines on the longer-term management of self-harm, currently chairs the guideline development group for the NICE depression in adults’ guidelines, is currently the topic advisor on the new NICE guideline on self-harm, and reports grants from the Department of Health and Social Care, National Institute of Health Research and NICE. All authors work with NHS England on the National Quality Improvement initiatives for suicide and self-harm. LA, NK, and PT report grants from the Health Quality Improvement Partnership.

ObjectiveWe aimed to spatially describe hospital admissions for ambulatory care sensitive conditions (ACSC) in England at small-area geographical level and assess whether recorded practice performance under one of the world’s largest primary care pay-for-performance schemes led to reductions in these potentially avoidable hospitalisations for chronic conditions incentivised in the scheme.SettingWe obtained numbers of ACSC hospital admissions from the Hospital Episode Statistics database and information on recorded practice performance from the Quality and Outcomes Framework (QOF) administrative dataset for 2015/2016. We fitted three sets of negative binomial models to examine ecological associations between incentivised ACSC admissions, general practice performance, deprivation, urbanity and other sociodemographic characteristics.ResultsHospital admissions for QOF incentivised ACSCs varied within and between regions, with clusters of high numbers of hospital admissions for incentivised ACSCs identified across England. Our models indicated a very small effect of the QOF on reducing admissions for incentivised ACSCs (0.993, 95% CI 0.990 to 0.995), however, other factors, such as deprivation (1.021, 95% CI 1.020 to 1.021) and urbanicity (0.875, 95% CI 0.862 to 0.887), were far more important in explaining variations in admissions for ACSCs. People in deprived areas had a higher risk of being admitted in hospital for an incentivised ACSC condition.ConclusionSpatial analysis based on routinely collected data can be used to identify areas with high rates of potentially avoidable hospital admissions, providing valuable information for targeting resources and evaluating public health interventions. Our findings suggest that the QOF had a very small effect on reducing avoidable hospitalisation for incentivised conditions. Material deprivation and urbanicity were the strongest predictors of the variation in ACSC rates for all QOF incentivised conditions across England.

Background: Paracetamol is frequently used for intentional self-poisoning, especially in the UK, despite pack size restrictions introduced in 1998. Knowing more about paracetamol self-poisoning may identify further approaches to prevention. Methods: We used data from the Multicentre Study of Self-harm in England for 2004–2014 to calculate incidence rates of presentations to Emergency Departments following self-poisoning with pure paracetamol alone. National estimates for England for 2011–2014 were extrapolated using indirect age-standardised rates. The characteristics of individuals taking paracetamol overdoses and the size of the overdoses were investigated. Results: A third of 54,863 intentional overdoses presenting to the five Emergency Departments involved paracetamol without other drugs (N = 18,011), taken by 13,171 individuals (63.4% female). The proportion of paracetamol self-poisonings was similar in the three centres. Extrapolation suggested there were approximately 50,000 paracetamol overdoses in England annually during 2011–2014. Females had higher rates of paracetamol overdose than males. Males and older individuals took larger overdoses. Nearly a quarter of individuals (24.2%) consumed more than 32 tablets. Alcohol was involved in 53.7% of paracetamol overdoses. Limitations: Data were collected in three centres with predominantly urban populations. Extrapolation from local to national rates should be interpreted with caution. Conclusions: Paracetamol overdose remains a major problem in the UK. It is more common in females and younger patients, but males and older patients consume larger overdoses. Consideration should be given to further restriction in pack sizes and sources of sales, in keeping with those of several other European countries.

BACKGROUND: To date, research on the indirect impact of the COVID-19 pandemic on the health of the population and the health-care system is scarce. We aimed to investigate the indirect effect of the COVID-19 pandemic on general practice health-care usage, and the subsequent diagnoses of common physical and mental health conditions in a deprived UK population.METHODS: We did a retrospective cohort study using routinely collected primary care data that was recorded in the Salford Integrated Record between Jan 1, 2010, and May 31, 2020. We extracted the weekly number of clinical codes entered into patient records overall, and for six high-level categories: symptoms and observations, diagnoses, prescriptions, operations and procedures, laboratory tests, and other diagnostic procedures. Negative binomial regression models were applied to monthly counts of first diagnoses of common conditions (common mental health problems, cardiovascular and cerebrovascular disease, type 2 diabetes, and cancer), and corresponding first prescriptions of medications indicative of these conditions. We used these models to predict the expected numbers of first diagnoses and first prescriptions between March 1 and May 31, 2020, which were then compared with the observed numbers for the same time period.FINDINGS: Between March 1 and May 31, 2020, 1073 first diagnoses of common mental health problems were reported compared with 2147 expected cases (95% CI 1821 to 2489) based on preceding years, representing a 50·0% reduction (95% CI 41·1 to 56·9). Compared with expected numbers, 456 fewer diagnoses of circulatory system diseases (43·3% reduction, 95% CI 29·6 to 53·5), and 135 fewer type 2 diabetes diagnoses (49·0% reduction, 23·8 to 63·1) were observed. The number of first prescriptions of associated medications was also lower than expected for the same time period. However, the gap between observed and expected cancer diagnoses (31 fewer; 16·0% reduction, -18·1 to 36·6) during this time period was not statistically significant.INTERPRETATION: In this deprived urban population, diagnoses of common conditions decreased substantially between March and May 2020, suggesting a large number of patients have undiagnosed conditions. A rebound in future workload could be imminent as COVID-19 restrictions ease and patients with undiagnosed conditions or delayed diagnosis present to primary and secondary health-care services. Such services should prioritise the diagnosis and treatment of these patients to mitigate potential indirect harms to protect public health.FUNDING: National Institute of Health Research.

Previous research suggests that up to 90% of individuals who die by suicide may have a mental disorder at the time of death but that levels of treatment may be low. This study aimed to examine undertreatment among patients with mental health conditions who died by suicide and to assess the association between patients' clinical and sociodemographic characteristics and treatment receipt.The study's sample included 12,909 patients in England and Wales who died by suicide within 12 months of contact with mental health services between 2001 and 2016. All patients had received a diagnosis of bipolar affective disorder, schizophrenia, depression, or an anxiety disorder. Records of patients who were not receiving treatment as recommended by national clinical guidelines at the time of death were examined for levels of nonprescription of treatment and nonadherence.Twenty-four percent of the patients did not receive treatment, 11% had not been prescribed treatment, and 13% were nonadherent with treatment. These proportions differed by diagnosis. After adjustment for main primary diagnosis, analyses showed that being under age 40, unemployment, living alone, drug misuse, medication side effects, and comorbid personality disorder were independently associated with a decreased likelihood of receiving treatment.One-quarter of patients with mental health conditions who die by suicide may not be receiving relevant interventions at the time of death. Levels of and reasons for nontreatment vary by diagnosis, but measures to address comorbid diagnoses and implement interventions to improve adherence in specific groups could have an impact.

ObjectivePeople with bipolar disorder are known to be at high risk of engaging in suicidal behaviours, and those who die by suicide have often been in recent contact with mental health services. The objective of this study was to explore suicidal behaviour in bipolar disorder and how this is monitored and managed by mental health services.AimsTo identify themes within relatives’ and service users’ accounts of mental healthcare, related to management and prevention of suicidal behaviour in bipolar disorder.DesignThematic analysis of 22 semistructured interviews.ParticipantsParticipants were aged 18 years or over, fluent in written and spoken English, and either had bipolar disorder with a history of suicidal behaviour, or were relatives of people with bipolar disorder who had died by suicide.SettingEngland, UK.Primary outcomeThemes identified from participants’ accounts of mental healthcare for suicidal behaviours in bipolar disorder.ResultsTwo main themes were identified. ‘Access to care’ was characterised by a series or cycle of potential barriers to care (eg, gate-keepers, lack of an accurate diagnosis) which had the potential to increase risk of suicidal behaviour if failure to access care continued over time. ‘Problems with communication’ captured the importance of maintaining open routes of communication between all parties involved in care to ensure successful monitoring and management of suicidal behaviours in bipolar disorder.ConclusionsMental health services need to be accessible and respond rapidly to people with suicidal behaviour in bipolar disorder. Open communication and inclusion of relatives in care, where appropriate, could help closer monitoring of changes in symptoms that indicate increased risk.

Background Suicide and non-fatal self-harm represent key patient safety events in mental healthcare services. However, additional important learning can also be derived by highlighting examples of optimal practice that help to keep patients safe. In this study, we aimed to explore clinicians’ views of what constitutes good practice in mental healthcare services in the context of suicide prevention. Methods Data were extracted from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) database, a consecutive case series study of suicide by people in contact with mental healthcare services. A large national sample of clinicians’ responses was analysed with a hybrid thematic analysis. Results Responses (n = 2331) were submitted by clinicians across 62 mental healthcare providers. The following five themes illustrated good practice that helps to: 1) promote safer environments, 2) develop stronger relationships with patients and families, 3) provide timely access to tailored and appropriate care, 4) facilitate seamless transitions, and 5) establish a sufficiently skilled, resourced and supported staff team. Conclusion This study highlighted clinicians’ views on key elements of good practice in mental health services. Respondents included practice specific to mental health services that focus on enhancing patient safety via prevention of self-harm and suicide. Clinicians possess important understanding of optimal practice but there are few opportunities to share such insight on a broader scale. A further challenge is to implement optimal practice into routine, daily care to improve patient safety and reduce suicide risk.

Background: Patient and public involvement (PPI) is becoming more commonplace in mental health research. There are strong moral and ethical arguments for good quality PPI. Few studies have documented and evaluated PPI in self-harm and suicide research. Inconsistent reporting of PPI makes it difficult to discern practices that deliver quality, effective and meaningful involvement. It is important to understand and address emotional support needs of PPI members contributing to sensitive topics such as suicide and self-harm. Therefore, this study will examine the effect of PPI on self-harm and suicide research and explore patients', carers' and researchers' experiences and views in relation to the quality of PPI practice and provision of appropriate support for PPI members. Methods: This protocol outlines the longitudinal, mixed methodological approach that will be taken. Qualitative and quantitative data will be collected via baseline and repeated questionnaires, document review and semi-structured interviews. Both PPI members and researchers will be invited to participate in this study. The two-year data collection period will enable evaluation of PPI throughout the entire research cycle. An integrated approach will be taken to data analysis, using inductive thematic analysis and descriptive and repeated measures analyses, to address specified study aims. Dissemination: Findings from this study will inform practical guidance to support self-harm and suicide researchers in effectively involving people with experiential knowledge in their research. Analyses will offer insight into the effect of PPI throughout the research process and assess changes in PPI members' and researchers' experiences of involvement across a two-year period.

Key Points Question Is SARS-CoV-2 infection associated with risk of subsequent psychiatric morbidity, sleep problems, or fatigue? Findings In this cohort study of the health care records of 11 923 105 patients, including 226 521 patients with SARS-CoV-2 infection, while infection was associated with increased risk of sleep problems and fatigue, associations with subsequent psychiatric morbidity were mixed. Meaning These findings suggest that psychiatric morbidity associated with SARS-CoV-2 infection may be overstated in analyses of health care records that do not sufficiently control for confounding., This cohort study assesses the association of SARS-CoV-2 infection with risk of incident or repeat psychiatric illness, fatigue, or sleep problems among individuals in the UK., Importance Infection with SARS-CoV-2 is associated with fatigue and sleep problems long after the acute phase of COVID-19. In addition, there are concerns of SARS-CoV-2 infection causing psychiatric illness; however, evidence of a direct effect is inconclusive. Objective To assess risk of risk of incident or repeat psychiatric illness, fatigue, or sleep problems following SARS-CoV-2 infection and to analyze changes according to demographic subgroups. Design, Setting, and Participants This cohort study assembled matched cohorts using the Clinical Practice Research Datalink Aurum, a UK primary care registry of 11 923 499 individuals aged 16 years or older. Patients were followed-up for up to 10 months, from February 1 to December 9, 2020. Individuals with less than 2 years of historical data or less than 1 week follow-up were excluded. Individuals with positive results on a SARS-CoV-2 test without prior mental illness or with anxiety or depression, psychosis, fatigue, or sleep problems were matched with up to 4 controls based on sex, general practice, and year of birth. Controls were individuals who had negative SARS-CoV-2 test results. Data were analyzed from January to July 2021. Exposure SARS-CoV-2 infection, determined via polymerase chain reaction testing. Main Outcomes and Measures Cox proportional hazard models estimated the association between a positive SARS-CoV-2 test result and subsequent psychiatric morbidity (depression, anxiety, psychosis, or self-harm), sleep problems, fatigue, or psychotropic prescribing. Models adjusted for comorbidities, ethnicity, smoking, and body mass index. Results Of 11 923 105 eligible individuals (6 011 020 [50.4%] women and 5 912 085 [49.6%] men; median [IQR] age, 44 [30-61] years), 232 780 individuals (2.0%) had positive result on a SARS-CoV-2 test. After applying selection criteria, 86 922 individuals were in the matched cohort without prior mental illness, 19 020 individuals had prior anxiety or depression, 1036 individuals had psychosis, 4152 individuals had fatigue, and 4539 individuals had sleep problems. After adjusting for observed confounders, there was an association between positive SARS-CoV-2 test results and psychiatric morbidity (adjusted hazard ratio [aHR], 1.83; 95% CI, 1.66-2.02), fatigue (aHR, 5.98; 95% CI, 5.33-6.71), and sleep problems (aHR, 3.16; 95% CI, 2.64-3.78). However, there was a similar risk of incident psychiatric morbidity for those with a negative SARS-CoV-2 test results (aHR, 1.71; 95% CI, 1.65-1.77) and a larger increase associated with influenza (aHR, 2.98; 95% CI, 1.55-5.75). Conclusions and Relevance In this cohort study of individuals registered at an English primary care practice during the pandemic, there was consistent evidence that SARS-CoV-2 infection was associated with increased risk of fatigue and sleep problems. However, the results from the negative control analysis suggest that unobserved confounding may be responsible for at least some of the positive association between COVID-19 and psychiatric morbidity.

ObjectivesWe sought to explore patient and carer experiences of psychosocial assessments following presentations to hospital after self-harm.DesignThematic analysis of free-text responses to an open-ended online survey.SettingBetween March and November 2019, we recruited 88 patients (82% women) and 14 carers aged ≥18 years from 16 English mental health trusts, community organisations, and via social media.ResultsPsychosocial assessments were experienced as helpful on some occasions but harmful on others. Participants felt better, less suicidal and less likely to repeat self-harm after good-quality compassionate and supportive assessments. However, negative experiences during the assessment pathway were common and, in some cases, contributed to greater distress, less engagement and further self-harm. Participants reported receiving negative and stigmatising comments about their injuries. Others reported that they were refused medical care or an anaesthetic. Stigmatising attitudes among some mental health staff centred on preconceived ideas over self-harm as a ‘behavioural issue’, inappropriate use of services and psychiatric diagnosis.ConclusionOur findings highlight important patient experiences that can inform service provision and they demonstrate the value of involving patients/carers throughout the research process. Psychosocial assessments can be beneficial when empathetic and collaborative but less helpful when overly standardised, lacking in compassion and waiting times are unduly long. Patient views are essential to inform practice, particularly given the rapidly changing service context during and after the COVID-19 emergency.

BackgroundObservations in psychiatric in-patient settings are used to reduce suicide, self-harm, violence and absconding risk. The study aims were to describe the characteristics of in-patients who died by suicide under observation and examine their service-related antecedents.MethodA national consecutive case series in England and Wales (2006–2012) was examined.ResultsThere were 113 suicides by in-patients under observation, an average of 16 per year. Most were under intermittent observation. Five deaths occurred while patients were under constant observation. Patient deaths were linked with the use of less experienced staff or staff unfamiliar with the patient, deviation from procedures and absconding.ConclusionsWe identified key elements of observation that could improve safety, including only using experienced and skilled staff for the intervention and using observation levels determined by clinical need not resources.

© 2016 Association for Child and Adolescent Mental Health Background: Self-harm in young people is a common reason for contact with clinical services. However, there is little research focusing on parents’ perspectives of care following self-harm. The aim of this study was to explore parents’ experiences of treatment and support for the young person and for themselves. Methods: A qualitative design was used to explore parents’ perspectives. Semi-structured narrative interviews were conducted across the UK with 37 parents of young people who had self-harmed. Thematic analysis was undertaken to identify themes relating to how parents experienced the help and treatment received. Results: Parents reported differing reactions to contact with helping services. Many found these helpful, particularly in keeping the young person safe, developing a trusting relationship with the young person, encouraging skills in managing self-harm and giving them an opportunity to talk about and find solutions to their difficulties. They spoke about the importance of practical help including prompt access to care, the right intensity of care, practical strategies and information and support. Some aspects of services were perceived as unhelpful, particularly a judgmental approach by professionals, lack of early access to treatment, inadequate support or failure to listen to the perspective of parents. Conclusions: Parents’ views highlight the need for clinicians to consider carefully the perspective of parents, involving them wherever possible and providing practical help and support, including written information. The need for training of clinicians in communicating with young people and parents following self-harm is also highlighted.

BackgroundJob loss, debt and financial difficulties are associated with increased risk of mental illness and suicide in the general population. Interventions targeting people in debt or unemployed might help reduce these effects.MethodWe searched MEDLINE, Embase, The Cochrane Library, Web of Science, and PsycINFO (January 2016) for randomized controlled trials (RCTs) of interventions to reduce the effects of unemployment and debt on mental health in general population samples. We assessed papers for inclusion, extracted data and assessed risk of bias.ResultsEleven RCTs (n= 5303 participants) met the inclusion criteria. All recruited participants were unemployed. Five RCTs assessed ‘job-club’ interventions, two cognitive behaviour therapy (CBT) and a single RCT assessed each of emotional competency training, expressive writing, guided imagery and debt advice. All studies were at high risk of bias. ‘Job club’ interventions led to improvements in levels of depression up to 2 years post-intervention; effects were strongest among those at increased risk of depression (improvements of up to 0.2–0.3s.d.in depression scores). There was mixed evidence for effectiveness of group CBT on symptoms of depression. An RCT of debt advice found no effect but had poor uptake. Single trials of three other interventions showed no evidence of benefit.Conclusions‘Job-club’ interventions may be effective in reducing depressive symptoms in unemployed people, particularly those at high risk of depression. Evidence for CBT-type interventions is mixed; further trials are needed. However the studies are old and at high risk of bias. Future intervention studies should follow CONSORT guidelines and address issues of poor uptake.

This chapter examines the global epidemiology of suicidal behaviour. Up to one million people die by suicide every year, and about three quarters of these are in low- and middle-income countries. Twenty to thirty times this number harm themselves or attempt suicide. Global rates are probably under-reported, and the iceberg model of suicidal behaviour (showing that much suicidal behaviour is ‘under the waterline’ and thus hidden) is a helpful way of conceptualizing this. In most countries, men are greatly over-represented amongst people who die by suicide. There is a current concern about men in midlife in many high-income settings. Although suicidal behaviour can vary widely in incidence, it tends to share common antecedents. However, it should be borne in mind that the results of large population-based studies do not always apply to individuals.

Suicide is a major public health and mental health challenge and claims as many as one million lives worldwide each year. It is also an individual tragedy with devastating consequences for family members, friends, and others who have been bereaved. Attempted suicide and suicidal behaviour are even more common. In recent years there has been an enormous amount of research and a growing realization that suicide can be prevented. There are approaches that we can use at societal and individual levels which will potentially save lives. This book provides a comprehensive but concise overview of the field of suicide prevention. It places suicide in a historical context before highlighting its complexity and possible causes. It goes on to discuss public health strategies and policy as well as psychological and pharmacological approaches to treatment and prevention. It also includes guidance for assessing people who present to services with suicidal thoughts or behaviours, along with a number of case vignettes. Suicide bereavement and technology-based approaches to intervention are discussed, and frequently asked questions on topics as diverse as enquiring about suicidal thoughts, rational suicide, and suicide terrorism are answered. This text is practical in its focus but strongly evidence-based and will be relevant to all those with an interest in preventing suicide.

This chapter discusses definitions of suicidal behaviour and some of the terminology used. There is no universally agreed nomenclature and a variety of terms have been used to capture the diversity of suicidal behaviour. Broadly speaking, approaches have tried to either categorize suicidal behaviour on the basis of intent or else regarded suicidal behaviour as along a continuum. Of course suicidal behaviour is exactly that—a behaviour and not a psychiatric disorder in its own right. A simple pragmatic approach to terminology might be most useful because this allows for flexible individualized clinical management.

This chapter takes a clinical perspective on the initial assessment and management of a person who presents with suicidal thoughts or behaviour. Establishing rapport is vitally important. Asking about suicidal intent, an enquiry about access to means of suicide, and an assessment of mental state are all required components of an assessment. A good assessment may itself be therapeutic. If there is evidence of a psychiatric disorder then appropriate evidence-based treatment should be initiated. Even when there is no evidence of a mental health problem, psychological interventions, follow-up, and other forms of support may be helpful. Research evidence suggests that we should consider offering formal psychological treatment to all those who present having harmed themselves.