| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
|
|
|
||||||||||
|
||||||||||||
Correspondence |
Centre for Suicide Prevention, University of Manchester, 7th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, UK
Correspondence: E-mail: Louis.Appleby{at}man.ac.uk
What conclusions should we draw from the article by Gairin et al (2003) on attendance at the accident and emergency department in the year before suicide? That if you do not do your homework, you will make mistakes. Although they criticise the National Confidential Inquiry and make 18 references to it, they do not seem to know what it does.
The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness has been based in Manchester since 1996, covering only one of the years studied by Gairin et al. It was set up to identify all deaths by suicide of people who had been under the care of specialist mental health services in the previous 12 months (Appleby et al, 1997). Our remit (not to mention our funding) does not extend to emergency departments. Our method of case ascertainment (Appleby et al, 2001) is to obtain lists of suicides and undetermined deaths from the Office for National Statistics and to check these against records held by local mental health services. We then collect further information from each patient's consultant psychiatrist. Gairin et al seem to think that we rely on voluntary reporting by health districts.
The Inquiry has been notified of 35 000 suicides since 1996 and has collected detailed information on over 9000 people in contact with mental health services. Gairin et al's assertion that we ‘must record the occurrence of hospital attendances for self-harm’ for all patients is a bold one, especially when it is based on five misclassified cases in one region. The issue is not whether self-harm is important, but the best way of collecting information about it in a national study. As a first step we are now carrying out a psychological autopsy study of 300 suicides by mental health patients, obtaining details of attendances in emergency departments and general practice, and interviewing the families of those who have died.
Gairin et al are also critical of policy makers for not recognising that self-harm is a key indicator of suicide risk. They must have missed the fact that the National Suicide Prevention Strategy for England includes a section on preventing suicide following self-harm (Department of Health, 2002).
The authors all work on the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness.
REFERENCES
Appleby, L., Shaw, J. & Amos, T. (1997)
National Confidential Inquiry into Suicide and Homicide by Confidential People
with Mental Illness. British Journal of Psychiatry,
170, 101
-102.
Appleby, L., Shaw, J., Sherratt, J., et al (2001) Safety First: Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. London: Department of Health.
Department of Health (2002) National Suicide Prevention Strategy for England. London: Department of Health.
Gairin, L., House, A. & Owens, D. (2003)
Attendance at the accident and emergency department in the year before
suicide: retrospective study. British Journal of
Psychiatry, 183, 28
-33.
Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, 15 HydeTerrace, Leeds LS2 9LT, UK
Yorkshire Centre for Forensic Psychiatry, Wakefield, UK
Authors' reply: We think that Appleby and colleagues have misunderstood what we are saying. Of course we are aware of the methods of case ascertainment used by the National Confidential Inquiry. Our main point is exactly that made by Appleby and colleagues – that the Inquiry is not set up in a way that enables it to identify suicides following attendances at accident and emergency departments. This is because specialist mental health services in the UK do not provide comprehensive monitoring of self-harm attendances, even of those referred for a specialist opinion, and yet the Inquiry does not seek evidence directly from accident and emergency departments about attendances following self-harm.
Self-harm is closely linked to suicide, and yet self-harm services are in a disorganised and underresourced state nationally. We see this as a challenge both to national policy makers and to local service providers. The National Suicide Prevention Strategy does indeed refer to self-harm. However, we find its recommendations couched in such general terms that it is unclear how real change will come about in services hard-pressed for staff or funding.
As a first step mental health trusts should be required to provide comprehensive self-harm services to accident and emergency departments, and acute hospitals and mental health services should collaborate to monitor all attendances that follow self-harm. This action would improve local service provision for a neglected and high-risk group, at the same time as solving the National Confidential Inquiry's monitoring problem.
We disagree with the National Director for Mental Health that the evidence is not strong enough to support such a policy; it is at least as good as the evidence for the wholesale introduction of standardised risk assessment in mental health services. If further evidence is needed, then we are not sure that a study restricted to ‘mental health patients’ (and therefore presumably excluding the very people we are discussing) is the answer. It would, however, be a relatively simple matter to attempt to replicate our findings in a multi-centre prospective monitoring study at those other centres that run accurate accident-and- emergency-based clinical databases.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
