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The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

Annual Report:: England, Northern Ireland, Scotland and Wales

• Homicide by mental health patients has fallen substantially since a peak in 2006, and the figures for the most recent confirmed years, 2009-2010, are the lowest since we began data collection in 1997 - 33 cases reported in 2010 (England). Delays in the Criminal Justice System and in data processing may have contributed but it is likely that this is a true fall in patient homicide. Clinical explanations may include improved management of dual diagnosis patients (in whom the rate had previously risen) and the community treatment order, introduced in 2008. A similar fall has been found for homicide by people with schizophrenia (22 in 2010) and for people with symptoms of mental illness at the time of the offence (36 in 2010).

• Suicide by mental health patients has risen - 1,333 deaths in 2011 (England). A change to the coding of causes of death has contributed to this figure and changes to the Mental Health Minimum Dataset (MHMDS) method make comparisons with earlier years difficult but it is likely that this is a true rise in patient suicide, following a previous fall. The rise probably reflects the rise in suicide in the general population, which has been attributed to current economic difficulties; the proportion of patients dying by suicide who were unemployed has risen in England and Northern Ireland. An apparent rise in Scotland is largely explained by the same coding change but the adjusted figure for patient suicide is still comparatively high. Increases in Wales and Northern Ireland are based on small numbers and should be treated with caution.

• In recent years there have been more suicides under home treatment or crisis resolution than under in-patient care (all countries). A substantial proportion of these deaths occur in patients who live alone or have refused treatment - home treatment may not be suitable for these patients without close supervision.

• Hanging remains the main method in patient suicides in England, Northern Ireland and Wales and has risen in these countries during the period 2001-2010. In Scotland, figures for hanging and self-poisoning are similar with self-poisoning slightly more common.

• Opiates are now the main substances taken by patients in fatal overdose (all countries). We do not know enough about which drugs are used and from where they are obtained.

• There is a continuing problem of substance misuse in patient suicide: our figures are high for alcohol misuse (highest in Northern Ireland and Scotland), drug misuse (highest in Scotland) and dual diagnosis (in all countries). In homicide, the figures are even higher: alcohol misuse (highest in Northern Ireland), drug misuse (highest in Scotland) and dual diagnosis (highest in Scotland).

• CTOs may have contributed to reduced patient homicide (England): our figures show that homicides have fallen in all patients and in those with schizophrenia, including those who were refusing treatment or losing contact with the service. However, these are early figures and further monitoring is needed. The effect of CTOs on patient suicide is unclear. CTO suicides may follow treatment refusal or loss of contact which they are designed to prevent, suggesting they could be applied more effectively (England, Wales, and Scotland).

• Patient suicide is still frequently preceded by missed contact with services (England, Scotland and Wales) and in Northern Ireland the numbers of such cases increased during the report period. Northern Ireland is the only UK country not to introduce assertive outreach teams (or an equivalent) although in England these teams are in some places being reabsorbed into general Community Mental Health Teams (CMHTs).

• Suicides by in-patients continue to fall (all countries), including in detained patients and those who have absconded.

• Victims of patient homicide are more likely to be spouses or family members than strangers (all countries).

• Sudden Unexplained Death (SUD) in in-patients continues to be associated with previous poor physical health (England and Wales). A quarter of SUD patients are under 45 years - physical ill-health is also common in this group and polypharmacy is found in 20% (England).

• Comprehensive figures for homicide and mental illness show that in 2001-2010 an average of 74 patients per year were convicted of homicide in the UK. When people with symptoms of mental illness are added, the total rises to an average of 115 per year. These are perpetrators - the corresponding figure for victims, taking account of multiple homicides, is 122 per year. All these figures appear to be falling.