Biomedical subjects

Louis Appleby

Publications and source records attributed to Louis Appleby.

At least 19 recordsLinked to original sources

PubMed2006

What predicts poor mother-infant interaction in schizophrenia?

BACKGROUND: Poor clinician-rated parenting outcome and observed interactive deficits in mothers with schizophrenia admitted to a psychiatric mother and baby unit (MBU) reflect continuing concerns over the parenting capacity of this group. However, little is known about whether interaction deficits are accounted for by severity of illness or adverse social circumstances typically experienced by these mothers. METHOD: Thirty-eight women with severe perinatal illness (schizophrenia n=13; affective disorders n=25) and their infants were observed in play interaction a week prior to MBU discharge. Clinical and sociodemographic data were also obtained. RESULTS: Mothers with schizophrenia and their infants were rated to have poorer interactive behaviour than the affective disorders group. Infant avoidance of the mother was associated with a lack of maternal sensitivity and responsiveness. The deficits in mother-infant interaction found in the schizophrenia group could not be accounted for by our measures of illness severity or factors relating to adverse social circumstances. CONCLUSIONS: The results replicate and extend previous findings showing poor interactive behaviours in mothers with schizophrenia, their infants, and in the dyad, in a range of areas following clinical recovery. The findings suggest that factors other than illness duration, dose of medication, marital status and occupational status are explanatory for the interactive deficits associated with maternal schizophrenia. Parenting interventions that aim to improve maternal sensitivity need to be developed specifically for this group.

Adult↗

PubMed2006

Suicide in psychiatric in-patients in England, 1997 to 2003.

BACKGROUND: Psychiatric in-patients are at particularly high risk of suicide but few studies have investigated trends in in-patient suicide over time. METHOD: We conducted a prospective study of all patients admitted to National Health Service (NHS) in-patient psychiatric care in England (1997-2003). The study was carried out as part of the National Confidential Inquiry into Suicide. The main outcome measure was death by suicide. Suicide rates were determined using Hospital Episode Statistics (HES) as the denominator. RESULTS: Between the first 2 years of the study (1997 and 1998) and the last 2 years of the study (2002 and 2003) the annual number of in-patient deaths from suicide fell from 187 to 156 (a 17% reduction). The rate of in-patient suicide fell by between 9% and 28% depending on which denominator was used. This fall was observed for both males and females, and was most marked for those aged 15-44 years. Reductions were also observed for the three most common methods of death (hanging, jumping, poisoning), but the trend for hanging did not reach statistical significance. Although the number of post-discharge suicides fell, the risk of post-discharge suicide (using admissions as a denominator) may have increased by as much as 10% during the study period. CONCLUSION: The rate of suicide among psychiatric in-patients appears to have fallen. The fall may reflect falling general population rates, changes in in-patient case mix, service improvements, or a transfer of risk to the post-discharge period. Services need to be aware of the importance of providing high quality aftercare following discharge from hospital.

Adolescent↗

PubMed2006

Self-harm in the UK: differences between South Asians and Whites in rates, characteristics, provision of service and repetition.

BACKGROUND: Rates of self-harm appear high in South Asian young women in the United Kingdom (UK) although previous studies were mostly small. Data on treatment and outcomes for South Asians are lacking. This study compared rates of self-harm, socio-demographic and clinical characteristics, provision of services and risk of repetition by ethnicity. METHOD: A prospective cohort of adult self-harm attendees (n = 7185), aged 15 and over presenting to four emergency departments in the cities of Manchester and Salford, UK over a 4-year period. RESULTS: The study included 299 South Asians. South Asian women aged 16-24 years were more likely to self-harm than Whites of the same age group (1010.9 vs. 754 per 100,000). Across all age groups the rates of self-harm were lower in South Asian men compared to White men and to South Asian women. South Asian women were significantly more likely to report relationship problems within the family than White women (32% vs. 19%, P = <0.001). South Asians were less likely than Whites to report depressive symptoms and to be offered specialist mental health services (Rate ratio = 0.75), and more likely to be referred back to the GP (Rate ratio = 1.83). South Asians were less likely to attend with a repeat episode (Rate ratio = 0.56). CONCLUSIONS: Young South Asian women are at high risk of self-harm, but their clinical risk appears to be lower in terms of the accepted contextual factors contributing to risk. Potentially useful service provision may include an interpersonal problem solving approach although to be effective, interventions would need to be acceptable to South Asian women and culturally appropriate.

Adolescent↗

PubMed2006

Suicide in recently released prisoners: a population-based cohort study.

BACKGROUND: Several studies have been undertaken on suicide in custody, but few on suicide after the release from prison. We undertook a population-based cohort study to investigate suicide rates in recently released prisoners in England and Wales. METHODS: We used the database of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness for England and Wales to identify all individuals who died by suicide or who received an open verdict at the coroner's inquest between 2000 and 2002. These records were linked to a Home Office register to identify all such deaths in people within 1 year of release from prison in England and Wales. We compared suicide rates per 100,000 person-years in these released prisoners with rates in the general population by using the indirectly age-standardised mortality ratio. FINDINGS: We identified 382 suicides occurring in 244 988 individuals within 1 year of release from prison; a suicide rate of 156 per 100 000 person-years. 79 (21%) suicides occurred within the first 28 days after release. In all age groups, suicide rates were higher in recently released prisoners than in the general population. The overall age-standardised mortality ratio for recently released prisoners was 8.3 (95% CI 7.5-9.3) for men and 35.8 (25.4-50.2) for women. INTERPRETATION: Recently released prisoners are at a much greater risk of suicide than the general population, especially in the first few weeks after release. The risk of suicide in recently released prisoners is approaching that seen in discharged psychiatric patients. A shared responsibility lies with the prison, probation, health, and social services to develop more collaborative practices in providing services for this high-risk group.

Adult↗

PubMed2006

Suicide in the homeless within 12 months of contact with mental health services : a national clinical survey in the UK.

BACKGROUND: Suicide prevention is a health service priority. Homeless mental health patients present a challenge to services because of their complex health and social needs. AIMS: To establish the numbers of homeless patients in contact with services who die by suicide; to describe their suicide methods and their social and clinical characteristics including aspects of clinical care. METHOD: A national clinical survey based on a 4-year (1996-2000) sample of people in England and Wales who died by suicide. Detailed data were collected on those who had been in contact with mental health services in the year before death. RESULTS: A total of 131 individuals who died by suicide were reported to have been homeless at the time of death--3% of all suicides by psychiatric patients, over 30 per year. Hanging was the most common cause of death. The most frequent diagnosis was schizophrenia. Around half were in-patients at the time of death. Social and clinical risk factors for suicide were common, including drug and alcohol misuse, and recent suicidal ideas and behaviour. Despite this, their clinical care was characterised by disengagement from services as a result of missed contacts, self-discharge, lack of follow-up and lack of key worker. CONCLUSIONS: In order to reduce the number of deaths by suicide in those who are homeless and mentally ill, improvements in in-patient safety and engagement in the community are needed. This may be achieved through assertive community treatment, dual diagnosis services, and dedicated community mental health teams.

Adolescent↗

PubMed2006

A clinical tool for assessing risk after self-harm.

STUDY OBJECTIVE: Our aim is to develop a risk-stratification model for use by emergency department (ED) clinical staff in the assessment of patients attending with self-harm. METHODS: Participants were patients who attended 5 EDs in Manchester and Salford, England, after self-harm between September 1, 1997, and February 28, 2001. Social, demographic, and clinical information was collected for each patient at each attendance. With data from the Manchester and Salford Self-Harm Project, a clinical decision rule was derived by using recursive partitioning to discriminate between patients at higher and lower risk of repetition or subsequent suicide occurring within 6 months. Data from 3 EDs were used for the derivation set. The model was validated with data from the remaining 2 EDs. RESULTS: Data for 9,086 patients who presented with self-harm were collected during this study period, including 17% that reattended within 6 months and 22 patients who died by suicide within 6 months. A 4-question rule, with a sensitivity of 94% (92.1-95.0% [95% confidence interval]) and specificity of 25% (24.2-26.5% [95% confidence interval]), was derived to identify patients at higher risk of repetition or suicide. CONCLUSION: Application of this simple, highly sensitive rule may facilitate assessment in the ED and help to focus psychiatric resources on patients at higher risk.

Adolescent↗

PubMed2006

A prospective study of noncompliance with medication, suicidal ideation, and suicidal behavior in recently discharged psychiatric inpatients.

Discharged psychiatric inpatients are at a greater risk of suicide in the three months following discharge. However, risk factors for this group are not clear. In this study 69 psychiatric inpatients were recruited and suicidal ideation, insight and compliance scores were measured at discharge and 12 weeks post-discharge. There were clinically significant rates of suicidal ideation (52%) and deliberate self harm (28%) in the post-discharge period. Over half of patients (52%) became noncompliant with medication. Subjects with lower insight scores at discharge were significantly more likely to become noncompliant. Suicidal ideation scores increased irrespective of compliance from discharge to follow-up and this increase was significantly greater in noncompliant subjects. We conclude that noncompliance with medication is associated with suicidal ideation.

Adolescent↗

PubMed2006

Suicide in schizophrenia: findings from a national clinical survey.

BACKGROUND: A reduction in suicide among individuals with mental illness is an international public-health priority. Approximately 10% of patients with schizophrenia will die by suicide. OBJECTIVE: The goal of this study was to describe social and clinical characteristics of people with schizophrenia who completed suicide, including aspects of the clinical care they received. METHOD: A national clinical survey was conducted based on a 4-year (1996-2000) sample of people in England and Wales who had died by suicide and had been in contact with mental health services in the previous 12 months. RESULTS: Of 20,927 individuals who committed suicide, 5,099 (24%) were known to have been in contact with mental health services in the year prior to death. Completed questionnaires were returned on 4,859 cases of suicide. Of these, 960 (20%) were diagnosed with schizophrenia. These suicides were characterized by more violent modes of death, with over a quarter (27%) jumping from a height or in front of a moving vehicle compared to 10% of the remaining sample. They were more likely than the other individuals in the sample to be young, male, unmarried, and from an ethnic minority with high rates of unemployment. Rates of previous violence and drug abuse were high and they were proportionally more likely to be inpatients at the time of death and to have been noncompliant with medication. Patients with schizophrenia and comorbid substance abuse showed particularly complex social and clinical morbidity. CONCLUSIONS: Measures that may prevent suicide among patients with schizophrenia include improved ward safety, closer supervision in both inpatient and community settings, particularly for those with poor medication compliance, and effective treatment of substance abuse.

Adolescent↗

PubMed2006

The role of alcohol and drugs in homicides in England and Wales.

BACKGROUND: The annual number of homicide convictions in England and Wales is increasing. Previous studies have highlighted the aetiological role of alcohol and drugs in homicide. AIMS: To examine rates of alcohol and drug misuse and dependence in people convicted of homicide; the role of alcohol and drugs in the offence; the social and clinical characteristics of alcohol- and drug-related homicides; and the social and clinical characteristics of patients with dual diagnosis who commit homicide. METHODS: A national clinical survey based on a 3-year (1996-9) consecutive sample of people convicted of homicide in England and Wales. Information on rates of alcohol and drug misuse/dependence, the role of alcohol and drugs in the offence and social and clinical characteristics of perpetrators were collected from psychiatric reports prepared for the court in homicide convictions. Detailed clinical information was gathered from questionnaires completed by mental health teams for those in contact with mental health services. RESULTS: Of the 1594 homicide perpetrators, more than one-third (42%) occurred in people with a history of alcohol misuse or dependence and 40% in people with a history of drug misuse or dependence. Alcohol or drug misuse played a contributory role in two-fifths of homicides. Alcohol played a major role in 52 (6%) and a minor role in 364 (39%) homicides. Drugs played a major role in six (1%) and a minor role in 138 (14%) homicides. Forty-two homicides (17%) were committed by patients with severe mental illness and substance misuse. Alcohol- and drug-related homicides were generally associated with male perpetrators who had a history of violence, personality disorders, mental health service contact and with stranger victims. CONCLUSIONS: Substance misuse contributes to the majority of homicides in England and Wales. A public health approach to homicide would highlight alcohol and drugs before severe mental illness.

Adolescent↗

PubMed2006

Evaluating STORM skills training for managing people at risk of suicide.

AIM: This paper reports a study evaluating the Skills Training On Risk Management (STORM) training initiative in three mental health services in the North-West of England, UK. BACKGROUND: Training for health workers has been widely advocated as a key route to suicide prevention. However, reports of evaluations are scarce in the literature. In previous research, we have demonstrated that the STORM intervention results in acquisition of new skills and can be disseminated in a community setting. METHOD: The training was delivered during a 6-month period in 2002 by three mental health nurses who were seconded part-time to the project. The quantitative evaluation, which assessed change in attitudes, confidence, acquisition of skills and satisfaction, used a pretest/post-test design, with participants acting as their own controls. Qualitative interviews were conducted with a purposive sample of 16 participants to explore the impact on clinical practice, and with the three trainers at the end of the study. FINDINGS: Data from 458 staff members were collected during a 6-month period. Positive changes in attitudes and confidence were shown, but previous evidence of skill acquisition was not replicated. Qualitative interviews revealed important insights into changes in clinical practice, particularly for less experienced or unqualified nursing staff, but also concerns about the lack of an educational culture to foster and support such interventions in practice within the organizations. CONCLUSION: STORM training for the assessment and management of suicide risk is both feasible and acceptable in mental health trusts. However, we remain uncertain of its longer-term impact, given the lack of engagement of senior staff in the enterprise and the absence of linked supervision and support from the organizational management to reinforce skill acquisition and development. We consider that regular supervision that links STORM training to actual clinical experience would be the ideal.

Adult↗

PubMed2006

Ecological association between suicide rates and indices of deprivation in the north west region of England: the importance of the size of the administrative unit.

BACKGROUND AND OBJECTIVE: Most published research on the ecological relationship between suicide rates and indices of deprivation uses only one level of population aggregation - for example, by local authorities. These ecological associations have been studied at both the local authority and the electoral ward level. METHODS: Data on all deaths for which suicide or an open verdict was returned between 1996 and 1998 in the North West Government Office Region (NWGOR) of England (2336 cases) were the subject of this study. These data were provided by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. The income and employment indices of deprivation and the population counts were provided by the Department of the Environment, Transport and the Regions, and the Office for National Statistics, respectively. RESULTS: Modelling data at the local authority and ward levels in the NWGOR showed that although at the local authorities level there are no significant associations between suicide rates and two indices, at the ward level there are significant associations. The direction of these associations is such that with an increase in the quartile ranks of each index (ie, with improving the situation of a ward in terms of that index), the rate of suicide decreases. CONCLUSION: A lack of effect was found once we move from ward to local authority level. This may happen because of the non-homogeneous nature of the local authorities in terms of their income and employment indices. In this sense, wards are more homogeneous. This means that in examining ecological risk factors, a balance was found between large areas (diluted effects but greater power) and small areas.

Adolescent↗

PubMed2006

Mortality risk among offspring of psychiatric inpatients: a population-based follow-up to early adulthood.

OBJECTIVE: The purpose of this article was to estimate relative risks of all-cause mortality associated with parental psychiatric disorder based on offspring age (up to 25 years of age), parental diagnosis, maternal versus paternal disorder, and number of affected parents. METHOD: The study group consisted of all Danish singleton live and stillbirths (N=1.46 million) during 1973-1998, identified using the Central Population Register and Medical Birth Register. Dates of death were recorded with follow-up to Jan. 1, 1999. Parental admission histories since 1969 were obtained from the Psychiatric Central Register. RESULTS: Mortality risks were elevated from birth through early adulthood among offspring of people admitted with any type of psychopathology, although relative risks were attenuated during school attendance years. Effect sizes varied according to offspring ages, the highest being during infancy. The following high-risk subgroups were identified: postneonates with two mentally ill parents, neonates and postneonates whose mothers had alcohol and drug-related disorders, and neonates whose mothers had affective disorders. In general, from the postneonatal period onward, there was no indication that maternal psychopathology is associated with higher offspring mortality risk than paternal disorder. CONCLUSIONS: The greatest number of excess deaths were attributable to alcohol-related disorders, this being the most prevalent paternal diagnostic category and the second most prevalent in mothers. Some findings were unexpected. For example, there was no evidence that mortality risk among offspring of parents with schizophrenia and related disorders was significantly greater than that associated with all other parental psychiatric conditions, whereas the relative risk for neonatal death associated with maternal affective disorders was markedly raised.

Adult↗

PubMed2006

Perpetrators of homicide with schizophrenia: a national clinical survey in England and Wales.

OBJECTIVE: Few studies have described rates of schizophrenia in a national sample of homicide perpetrators. This study aimed to describe this group's social and clinical characteristics, mental state features, offense details, and outcome in court. METHOD: Analyses used a national clinical survey that collected data on people convicted of homicide in England and Wales (1996-1999). Data were collected for those with schizophrenia or other delusional disorders from psychiatric reports and questionnaires. RESULTS: Of the 1,594 people convicted of homicide, 85 (5 percent) had schizophrenia. Of the 57 people with schizophrenia for whom data were available, 32 (56 percent) had been ill for less than 12 months, and in the month before the offense, 32 (56 percent) had shown a change in the quality, intensity, or conviction of or emotional response to their delusional beliefs. Twenty-four (28 percent) had no previous contact with psychiatric services. CONCLUSIONS: Regular assessment of delusions may help to detect an increased risk of violence, including homicide. More intensive care should be available for patients with a history of schizophrenia and previous violence.

Adult↗

PubMed2006

Suicide in mental health in-patients and within 3 months of discharge. National clinical survey.

BACKGROUND: Suicide prevention is a health service priority. Suicide risk may be greatest during psychiatric in-patient admission and following discharge. AIMS: To describe the social and clinical characteristics of a comprehensive sample of in-patient and post-discharge cases of suicide. METHOD: A national clinical survey based on a 4-year (1996-2000) sample of cases of suicide in England and Wales who had been in recent contact with mental health services (n=4859). RESULTS: There were 754 (16%) current in-patients and a further 1100 (23%) had been discharged from psychiatric in-patient care less than 3 months before death. Nearly a quarter of the in-patient deaths occurred within the first 7 days of admission; 236 (31%) occurred on the ward, the majority by hanging. Post-discharge suicide was most frequent in the first 2 weeks after leaving hospital; the highest number occurred on the first day. CONCLUSIONS: Suicide might be prevented among in-patients by improving ward design and removing fixtures that can be used in hanging. Prevention of suicide after discharge requires early community follow-up and closer supervision of high-risk patients.

Adolescent↗

PubMed2006

Suicide within 12 months of mental health service contact in different age and diagnostic groups: National clinical survey.

BACKGROUND: Suicide prevention is a health service priority but the most effective approaches to prevention may differ between different patient groups. AIMS: To describe social and clinical characteristics in cases of suicide from different age and diagnostic groups. METHOD: A national clinical survey of a 4-year (1996-2000) sample of cases of suicide in England and Wales where there had been recent (<1 year) contact with mental health services (n=4859). RESULTS: Deaths of young patients were characterised by jumping from a height or in front of a vehicle, schizophrenia, personality disorder, unemployment and substance misuse. In older patients, drowning, depression, living alone, physical illness, recent bereavement and suicide pacts were more common. People with schizophrenia were often in-patients and died by violent means. About a third of people with depressive disorder died within a year of illness onset. Those with substance dependence or personality disorder had high rates of disengagement from services. CONCLUSIONS: Prevention measures likely to benefit young people include targeting schizophrenia, dual diagnosis and loss of service contact; those aimed at depression, isolation and physical ill-health should have more effect on elderly people.

Adult↗

PubMed2006

Rates of mental disorder in people convicted of homicide. National clinical survey.

BACKGROUND: Previous studies of people convicted of homicide have used different definitions of mental disorder. AIMS: To estimate the rate of mental disorder in people convicted of homicide; to examine the relationship between definitions, verdict and outcome in court. METHOD: A national clinical survey of people convicted of homicide (n=1594) in England and Wales (1996-1999). Rates of mental disorder were estimated based on: lifetime diagnosis, mental illness at the time of the offence, contact with psychiatric services, diminished responsibility verdict and hospital disposal. RESULTS: Of the 1594,545 (34%) had a mental disorder: most had not attended psychiatric services; 85 (5%) had schizophrenia (lifetime); 164 (10%) had symptoms of mental illness at the time of the offence; 149 (9%) received a diminished responsibility verdict and 111 (7%) a hospital disposal - both were associated with severe mental illness and symptoms of psychosis. CONCLUSIONS: The findings suggest an association between schizophrenia and conviction for homicide. Most perpetrators with a history of mental disorder were not acutely ill or under mental healthcare at the time of the offence. Some perpetrators receive prison sentences despite having severe mental illness.

Adolescent↗

PubMed2006

The repetition of suicidal behavior: a multicenter cohort study.

OBJECTIVES: To determine the proportion of individuals who repeated nonfatal suicidal behavior within 12 months of an index episode, to investigate the timing of repetition, and to investigate risk factors associated with repetition and their population impact. METHOD: We carried out a prospective cohort study (1997-2002) in 4 large hospitals in North West England. We included subjects aged 15 years and over who attended with "self-harm" (an act of intentional self-poisoning or injury irrespective of the apparent purpose of the act). Following the episode, a standard assessment form, which included detailed demographic and clinical data, was completed by a clinician. RESULTS: 9213 individuals presented during the study period. The incidence of repetition within 12 months of the index episode was 13.6% (95% CI: 12.9% to 14.4%). The median time to first repetition was 73.5 days (interquartile range, 20 to 187 days). One in 10 subjects repeated within 5 days of the index episode. Independent risk factors for repetition included previous suicidal behavior, psychiatric treatment, being unemployed or registered sick, self-injury, alcohol misuse, and reporting suicidal plans or hallucinations at the time of the index episode. The combined population attributable fraction (an indicator of the potential population impact) for these variables was 65%. CONCLUSION: The repetition of suicidal behavior is common and occurs quickly. On a population level, our study suggests that the most important strategies to reduce repetition might include primary prevention of suicidal behavior, targeting psychiatric illness, and tackling social factors such as unemployment. Specific interventions may be required for individual subgroups.

Adolescent↗

PubMed2005

The ecological association between suicide rates and indices of deprivation in English local authorities.

INTRODUCTION: There are several published studies that have been focused on the ecological association between suicide rates in different areas with indices of deprivation or fragmentation. Most of these studies, however, have used census-based indices of deprivation or fragmentation. In the present study the newly developed Indices of Deprivation have been used, taking into account the results of the spatial autocorrelation tests. METHODS: Data on all deaths for which suicide or an open verdict was returned during 1996-1998 in England were subjects of this study. These data were provided by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. The indices of deprivation and the population counts were provided by the Department of the Environment, Transport and the Region (DETR) and Office for National Statistics (ONS), respectively. RESULTS: The results show that, in England as a whole, the rates of suicide in young and middle-aged males were strongly associated with the indices of deprivation. However, the rates of suicide in females and in older age groups were less influenced by the indices of deprivation. In the present study all the indices of deprivation tended to show a similar pattern in which a better socio-economic status of local authorities was associated with a lower rate of suicide. CONCLUSION: These findings suggest that at the local authority level, the "hot spots" index of deprivation may represent the same level of magnitude in predicting the rates of suicide as the number of unemployed or income-deprived people. However, more studies using multilevel modelling are needed to shed more light on the ecological associations between suicide rates and socio-economic and social cohesion status.

Adolescent↗