Seasonal and socio-demographic predictors of suicide in Ireland: a 22 year study.

BACKGROUND: Seasonal influences on suicide have been studied for many years with inconclusive and contradictory findings. METHODS: Data on suicide in Ireland from 1980 to 2002 was examined to ascertain the contribution of season and demographic variables to suicide. Using Poisson regression modelling and sinusoidal analysis a small seasonal effect (7% from peak to trough) was identified but age, gender, marital status and residence were much larger contributors. The seasonal contribution increased in the latter half of the period under study. There was also a small seasonal effect for method of suicide. The suicide rate was highest in the 40-44 age group after controlling for confounders. LIMITATIONS: Because this was an ecological study, information on other possible contributors, such as mental illness was not available. CONCLUSIONS: These findings are discussed in light of international studies. Continuing studies are required to confirm the trend in increasing seasonality in Ireland. Since suicide is highest in those who are middle aged, preventive strategies should be directed to this group.

The incidence and associated risk factors for sudden unexplained death in psychiatric in-patients in England and Wales.

Clinical characteristics and risk factors associated with sudden unexplained death (SUD) in the psychiatric population are unclear. Psychiatric in-patients (England, Wales) who met criteria for SUD were identified (1 March 1999-31 December 2005). Cases were matched with controls (in-patients alive on the day a SUD occurred). Data were collected via questionnaires. Some 283 cases of SUD were identified (41 annually), with a rate of 2.33/10,000 mental health admissions (in England). Electrocardiograms were not routine, cardiopulmonary resuscitation equipment was sometimes unavailable, attempts to resuscitate patients were carried out on one-half of all patients and post mortems/inquiries were not routine. Restraint and seclusion were uncommon. Risk factors included: benzodiazepines (odds ratio (OR): 1.83); ≥ 2 antipsychotics (OR: 2.35); promazine (OR: 4.02); diazepam (OR: 1.71); clozapine (OR: 2.10); cardiovascular disease (OR: 2.00); respiratory disease (OR: 1.98); diagnosis of dementia (OR: 2.08). Venlafaxine and a diagnosis of affective disorder were associated with reduced ORs (OR: 0.42; OR: 0.65). SUD is relatively rare, although it is more common in older patients and males. Prevention measures may include safer prescribing of antipsychotics and improved physical health care. The contribution of restraint or seclusion to SUD in individual cases is unclear. A uniform definition of SUD may help to identify contributing factors.

'We can't get anything done because...': making sense of 'barriers' to Practice-based Commissioning.

OBJECTIVES: To investigate the issues raised by participants as 'barriers' to the development of Practice-based Commissioning (PBC) in 'early adopter' sites in England. METHODS: Detailed case studies of five PBC consortia in three Primary Care Trusts (PCTs). Data collection included interviews with a wide range of respondents (46 in total), including general practitioners, PCT employees, Local Authority employees and patient representatives, observation of many different types of meetings (68 in total), and analysis of documents tabled at meetings and circulated at other times. RESULTS: It has been claimed that progress in developing PBC has been slow. Our respondents articulated a number of factors that they felt were holding them back, which could have been identified as 'barriers' preventing change. The issues raised were consistent across our sites (lack of time, resources and personnel, and difficult relationships with the PCT), but observation suggested that these issues arose out of very different organizational 'sensemaking', and as a result the apparent 'barriers' had different meanings in different organizational contexts. CONCLUSION: Weick's concept of 'organizational sensemaking' provides a useful framework within which to explore the problems encountered when implementing policy. Observational methods are a powerful tool in understanding sensemaking. The variations in sensemaking that we observed suggest that the use of 'barrier' metaphors in descriptions of implementation problems risks homogenizing the portrayal of situations that differ greatly in reality. This implies that top-down or centrally driven solutions to such situations will often be inappropriate.

Deaths from natural causes in people with mental illness: a cohort study.

OBJECTIVES: To investigate natural-cause mortality risk in people with psychiatric admission histories in a national population-based cohort. To estimate risks in relation to psychiatric diagnostic categories and for specific causes of death. METHODS: We studied a 21-year cohort (1973-93) of 4.1 million Danish adults with linkage to national psychiatric and mortality registers. Person years were stratified by psychiatric diagnostic category and age-standardized mortality ratios (SMRs) were estimated versus the general population. RESULTS: Risks of death by natural causes were higher across a range of psychiatric illnesses in both sexes. We observed SMRs greater than 200 in men and women with alcoholism, drug abuse, organic psychoses, dementia, and learning difficulties. Alcoholism and drug misuse in particular were important causes of premature mortality. The highest cause-specific SMRs were for nervous system diseases, gastrointestinal diseases, lung diseases, and "all other natural causes"; the lowest were for neoplasm. The greatest excess, in terms of absolute numbers, was for circulatory disease mortality. CONCLUSION: Adults experiencing a range of psychiatric illnesses are more likely to die at any age, and also prematurely, from natural causes. The consistency of elevated risk across psychiatric diagnoses and causes of death indicates an important health inequality. Those involved in planning and providing mental health services should address the heightened need for physical health care in psychiatric patients.

Pay-for-performance programs in family practices in the United Kingdom.

BACKGROUND: In 2004, after a series of national initiatives associated with marked improvements in the quality of care, the National Health Service of the United Kingdom introduced a pay-for-performance contract for family practitioners. This contract increases existing income according to performance with respect to 146 quality indicators covering clinical care for 10 chronic diseases, organization of care, and patient experience. METHODS: We analyzed data extracted automatically from clinical computing systems for 8105 family practices in England in the first year of the pay-for-performance program (April 2004 through March 2005), data from the U.K. Census, and data on characteristics of individual family practices. We examined the proportion of patients deemed eligible for a clinical quality indicator for whom the indicator was met (reported achievement) and the proportion of the total number of patients with a medical condition for whom a quality indicator was met (population achievement), and we used multiple regression analysis to determine the extent to which practices achieved high scores by classifying patients as ineligible for quality indicators (exception reporting). RESULTS: The median reported achievement in the first year of the new contract was 83.4 percent (interquartile range, 78.2 to 87.0 percent). Sociodemographic characteristics of the patients (age and socioeconomic features) and practices (size of practice, number of patients per practitioner, age of practitioner, and whether the practitioner was medically educated in the United Kingdom) had moderate but significant effects on performance. Exception reporting by practices was not extensive (median rate, 6 percent), but it was the strongest predictor of achievement: a 1 percent increase in the rate of exception reporting was associated with a 0.31 percent increase in reported achievement. Exception reporting was high in a small number of practices: 1 percent of practices excluded more than 15 percent of patients. CONCLUSIONS: English family practices attained high levels of achievement in the first year of the new pay-for-performance contract. A small number of practices appear to have achieved high scores by excluding large numbers of patients by exception reporting. More research is needed to determine whether these practices are excluding patients for sound clinical reasons or in order to increase income.

Emergency department management and outcome for self-poisoning: a cohort study.

Self-poisoning in adults is an important public health problem across the world, but evidence to guide psychological management is lacking. In the current cohort study we wished to investigate whether aspects of routine Emergency Department management such as receiving a psycho-social assessment, or being referred for specialist follow up, affected the rate of repetition of self-poisoning. The study was carried out in four inner city hospitals in Greater Manchester, United Kingdom, over a 5-month period. We used hospital information systems and reviewed the case notes of every patient presenting to the Emergency Department to identify prospectively all adult patients presenting with deliberate self-poisoning. Data regarding the Emergency Department management of each episode were collected. The Manchester and Salford self-harm database was used to determine the number of individuals who went on to repeat self-poisoning within 6 months of their index episode. During the recruitment period 658 individuals presented with self-poisoning. Traditional risk factors for repetition such as substance dependence, psychiatric contact, and previous self-poisoning were associated with a greater likelihood of receiving a psycho-social assessment or being referred for specialist follow-up. Ninety-six patients (14.6%) repeated self-poisoning within 6 months of their index episode. After adjustment for baseline demographic and clinical characteristics and hospital, receiving a psycho-social assessment was not associated with reduced repetition but being referred for specialist follow-up was [adjusted hazard ratio for repetition (95% CI): 0.49 (0.25 to 0.84), P=.01]. We found that being referred for active follow-up after self-poisoning was associated with a reduced risk of repetition. The implications of this finding are discussed. Further studies using both cohort and randomized controlled study designs will help inform management strategies for patients who poison themselves.

Factors that influence emergency department doctors' assessment of suicide risk in deliberate self-harm patients.

OBJECTIVES: To determine the patient factors influencing UK Emergency Department doctors' assessment of suicide risk. To establish whether immediate clinical management is consistent with perceived risk. METHODS: The Manchester and Salford Self-Harm project is a multi-centre deliberate self-harm monitoring study. Data collected were used to analyse risk assessments made by Emergency Department doctors between September 1997 and August 1999. We used univariate and logistic regression analyses to determine the factors Emergency Department doctors used to make suicide risk assessments. RESULTS: A total of 3220 deliberate self-harm assessment forms were completed in two years by Emergency Department doctors; 2922 (91%) included a clinical assessment of risk; 28 out of 48 variables were associated with perceived suicide risk. Multiple logistic regression analyses showed that current mental state, high suicidal intent (including medical seriousness of attempt), and male sex were the most important independent predictors of suicide risk. Being referred to psychiatric services directly from the Emergency Department or to surgical/medical services was also strongly associated with a perceived high risk. CONCLUSION: In contrast to the negative findings of previous research, we found that Emergency Department doctors were influenced by key risk factors for suicide in their assessment of deliberate self-harm patients. Emergency Department doctors' assessments reflected the immediate risk of suicide, indicated by factors such as current mental state and strong suicidal intent. Background risk factors such as social adversity and psychiatric history were less influential. We would recommend that training for emergency doctors should emphasize the importance of both immediate and background risk factors.