Suicide, Self-Harm and Premature Death following First Episode Psychosis

Lead Research Organisation: King's College London
Department Name: Unlisted

Abstract

People who commit suicide have often suffered with mental health problems. Psychotic disorders (such as Schizophrenia and Bipolar Disorder) are severe mental illnesses of disturbed thoughts, feelings, mood and behaviours. These diseases strike when people are young and affect 1 in 50 of the population.

Suicides tend to occur early in the course of the illness, but the true rate of suicide after a first episode of illness or any change in rate over the last few decades has not been studied effectively.

For this research, I want to trace a group of 3000 patients who suffered their first psychotic illness between 1965-2004 and find out what the suicide rate and death rate from other causes is. I will investigate if there have been any changes in rate over the last four decades and research possible risk factors that relate to individuals, their neighbourhood or health services.

I will also follow-up 500 patients more closely, 10 years after they first became ill, to study self-harm in more detail. It will be important to know whether the risk factors for self-harm are the same as for suicide, so that strategies to prevent self-harm and suicide can be developed.

Technical Summary

Background - The high risk of suicide in psychotic disorders is well recognised, but may have been overestimated by studying unrepresentative samples. Time trends in suicide rate are poorly understood. There is conflicting evidence about deaths from other causes and knowledge about risk factors for suicide and self-harm is limited.

Aims and Objectives - 1. To describe suicide, self-harm and mortality rates in a cohort study of 3000 first episode psychosis patients from three geographically defined areas. 2. To study any change in rates of suicide over four decades. 3. To identify risk factors for suicide and self-harm.

Design - Cohort study with first presentation as entry point and death / emigration / Office for National Statistics (ONS) trace date as end point.

Methodology - The cohort will be formed from three comparable datasets of all first episode psychosis cases from geographical catchment areas in London, Nottingham and Scotland. ONS tracing will be used to identify those patients who have died and their cause of death. Survival analysis involving a lexis expansion and Poisson Regression will be used to establish person-year rates of suicide and investigate individual (sociodemographic and clinical) and neighbourhood level (deprivation, social cohesion, urbanicity) risk factors for suicide and self-harm. Indirect standardisation will be used to calculate Standardised Mortality Ratios (SMRs) for suicide and other causes of death, standardised for age, sex and where possible ethnicity. A subset (n=500) have extensive clinical interview data from baseline and will be intensively followed-up using 10-year Life Chart information and Insight Schedules to determine further risk factors for self-harm.

Scientific / Medical opportunities of the study - It is important to have accurate suicide and death rates following first episode psychosis, stratified by age, sex and ethnicity, to identify areas of health service need. If changes over time are found, either overall or in particular subgroups, this will generate further hypotheses to be tested in subsequent studies. Understanding risk factors for suicide and self-harm may suggest strategies for prevention.

Publications

10 25 50
 
Description Citation in review of the current literature regarding suicide risk
Geographic Reach Multiple continents/international 
Policy Influence Type Citation in clinical reviews
Impact Evidence from my research shows that the widely discussed suicide risk of 10% in psychosis is an inflated estimate. There is an obvious danger of overestimating suicide risk in studies with a limited follow-up period and in those biased towards patients with more severe disease. Suicide appears to occur approximately 12 times more than expected in the general population and males are prone to use violent methods. Although the rates of suicide are highest in young patients early in the course of illness, suicide is not just a phenomenon of early psychosis. Of clinical importance is the consistently high risk in later years, with the risk of suicide remaining almost four times higher than that in the general population after a decade. This is encouraging higher clinical vigilance later in the course of illness.
 
Description SLaM Suicide Prevention Working Party
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Membership of a guideline committee
Impact Improvements in clinical service delivery of suicide prevention pathways at a local and regional level. Models may be adopted nationally. Dr Dutta is also the Academic Suicide Lead of the KHP Faculty of Healthcare Improvement Safety Connections Network - focusing on harm-free care from a leadership, teamwork, educational and communication perspective and tasked with promoting patient safety, improving patient experience, helping staff develop new skills, and developing innovations and improvements within the organisation.
 
Description The Health Committee Suicide Prevention Inquiry
Geographic Reach National 
Policy Influence Type Gave evidence to a government review
URL http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/health-committee/su...
 
Description Clinician Scientist Fellowship - The Health Foundation/Academy of Medical Sciences
Amount £825,876 (GBP)
Organisation Academy of Medical Sciences (AMS) 
Sector Charity/Non Profit
Country United Kingdom
Start 03/2014 
End 06/2020
 
Description Data Science Award - 2018-19: Using Data Science to understand educational risk factors for self-harm and suicidal behaviour in young people
Amount £49,996 (GBP)
Funding ID MQDS16/52 
Organisation MQ Transforming Mental Health 
Sector Charity/Non Profit
Country United Kingdom
Start 03/2018 
End 02/2020
 
Description Margaret Temple Research Grant (2011)
Amount £49,460 (GBP)
Funding ID PCSTXZE 
Organisation British Medical Association (BMA) 
Sector Learned Society
Country United Kingdom
Start 09/2011 
End 08/2014
 
Description Margaret Temple Research Grant (2014)
Amount £20,643 (GBP)
Organisation British Medical Association (BMA) 
Sector Learned Society
Country United Kingdom
Start 09/2014 
End 08/2017
 
Description Mark Robinson MRCVS PhD Scholarship
Amount £120,000 (GBP)
Organisation Mental Health Research UK (MHRUK) 
Sector Charity/Non Profit
Country United Kingdom
Start 10/2014 
End 09/2017
 
Description NIHR Clinical Research Fellowship - 2017-21: Self-Harm in the Perinatal Period: Prevalence, Risk Factors and Prediction - Co-applicant
Amount £322,437 (GBP)
Funding ID DRF-2016-09-042 
Organisation National Institute for Health Research 
Department National Institute for Health Research (NIHR) BioResource
Sector Academic/University
Country United Kingdom
Start 02/2018 
End 01/2021
 
Description Research Contract - 2017-18: MeDESTO - Measuring Duration of untreated psychosis by Extraction of Symptom and Treatment Onset from mental health records using language technology
Amount £136,423 (GBP)
Organisation Swedish Research Council 
Sector Public
Country Switzerland
Start 01/2018 
End 12/2018
 
Description Self-harm database linkage project
Amount £79,000 (GBP)
Organisation South London and Maudsley (SLAM) NHS Foundation Trust 
Department Maudsley Charity
Sector Charity/Non Profit
Country United Kingdom
Start 01/2014 
End 01/2016
 
Description Social media, Smartphone use and Self-harm in Young People (3S-YP study)
Amount £500,000 (GBP)
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 09/2019 
End 08/2022
 
Title Camberwell-Dumfries and Galloway-Nottingham Merged First Episode Psychosis Cohort 
Description A merged cohort of 2723 patients who presented for the first time with psychosis in three defined geographical catchment areas in London (1965-2004;n=2056), Nottingham (1997-1999;n=203) and Dumfries and Galloway (1979-1998;n=464) and were traced after mean 11.5 years follow-up. 
Type Of Material Improvements to research infrastructure 
Provided To Others? No  
Impact The development of this merged cohort has allowed me to reassess the long-term risk of suicide after a first episode of psychosis and show that the widely held view that 10-15% die of suicide is misleading (to be published December 2010 in Archives of General Psychiatry). 
 
Description Centro de Investigación Biomedica, Madrid, Spain 
Organisation Spanish National Research Council (CSIC)
Department Biological Research Center
Country Spain 
Sector Private 
PI Contribution Begun to collaborate on papers via institutional links with Dr Rosa Ayesa-Arriola.
Collaborator Contribution Data from partners, analysed for one publication to date.
Impact Data-based peer reviewed publication - Suicidal behaviour in first-episode non-affective psychosis: Specific risk periods and stage-related factors Ayesa-Arriola, R., Alcaraz, E. G., Hernández, B. V., Pérez-Iglesias, R., López Moríñigo, J. D., Dutta, R., David, A. S., Tabares-Seisdedos, R. & Crespo-Facorro, B. Dec 2015 In : European Neuropsychopharmacology. 25, 12, p. 2278-2288
Start Year 2014
 
Description Barbican Debate: Battle of Ideas 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Type Of Presentation Keynote/Invited Speaker
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact ~ 200 members of the public attended a public debate entitled 'Suicide: the ultimate selfish act?' which prompted debate and discussion.

(1) Members of the public have become more interested in the research I am undertaking at KCL and want to participate in future public events organised for research finding dissemination; (2) I have made an important public engagement link with the mental health charity 'SANE'; (3) I have been invited back for a further debate at the Battle of Ideas in 2014.
Year(s) Of Engagement Activity 2013
URL http://www.battleofideas.org.uk/index.php/2013/session_detail/7862
 
Description Founding SUMMIT (the SUicide, self-harM and Mortality InTerest group) Forum at King's Health Partners 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact The award holder (Dr Rina Dutta) founded SUMMIT in 2012, heading up a working group of colleagues, Drs Sean Cross, William Lee, Paul Moran and Dennis Ougrin. The SUMMIT forum brings both academics and clinicians from the Institute of Psychiatry, King's College London, Guy's, St Thomas' and King's College Hospitals and South London and the Maudsley NHS Foundation Trust together for collaborative working. It also sparks outside regional interest and attendance from non-King's Health Partners staff with a view to expanding further. http://www.kcl.ac.uk/iop/depts/pm/events/SUMMIT.aspx

New research and educational collaboration has been fostered between academics and clinicians from across King's Health Partners. This has resulted in MSc projects being offered with dual academic and clinician supervision in the field of self-harm and suicide, and these have been popular, generating competition amongst 2012/13 applicants.
Year(s) Of Engagement Activity 2012
 
Description King's Health Partners Safety Connections 2012 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Workshop Facilitator
Geographic Reach National
Primary Audience Health professionals
Results and Impact Approximately 30 Health professionals attended the workshop, with interactive questions and debate throughout.

Recruitment of Health professionals interested in becoming self-harm and suicide prevention trainers within King's Health Partners. Collaborative links formed with clinicians (nationally) interested in self-harm and suicide research. Regional interest generated in SUMMIT (the SUicide, self-harM and Mortality InTerest group) at King's Health Partners founded by the award holder (Rina Dutta) in 2012. This latter has resulted in increased attendance and participation at meetings, including 10th September 2012 - Seminar marking 10th World Suicide Prevention Day (organised by the International Association for Suicide Prevention (IASP) in official relations with WHO) http://www.kcl.ac.uk/iop/depts/pm/events/SUMMIT.aspx
Year(s) Of Engagement Activity 2012
 
Description Management of suicide risk workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Participants in your research and patient groups
Results and Impact I conducted 2 afternoon workshops, each with approximately 50 attendees using case studies in an interactive manner. The aim was to facilitate discussion of issues concerning suicide risk in a multidisciplinary setting involving small groups of patients with clinicians and other NHS staff including adminisitrators and managers. The findings of my research were discussed in the plenary session.

The medical director and trust organisers have asked me to develop the idea of small group discussion of case scenarios and integration of research findings into future events. Patient groups appreciated being involved in the early dissemination of the latest results from this research.
Year(s) Of Engagement Activity 2010
 
Description NHS Foundation Trust presentation to clinicians and patients. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Health professionals
Results and Impact Approximately 200 health professionals and patients attended this talk as part of a 'Learning lessons from Suicides and Homicides' awareness day. Many questions and a lot of discussion was generated, sparking new ideas for future work.

Request from the Trust to present an update on research findings at similar events within South London and Maudsley NHS Foundation Trust in the future.
Year(s) Of Engagement Activity 2010
 
Description Presentation to mental health workers in Kolkata, India 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Health professionals
Results and Impact Approximately 100 mental health care workers including psychiatrists, psychologists, nurses and social workers attended a presentation of my suicide research and a discussion followed concerning the challenges of conducting parallel research in India. There was a lot of interest in the research techniques I used and the means of conducting a long-term cohort study.

Invitation to return and present future research findings and lead discussion concerning psychosis research in Kolkata at Institute of Postgraduate Medical Education and Research.
Year(s) Of Engagement Activity 2010
 
Description SUMMIT seminars 2012-17 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Regular attendance at seminars of ~ 30-40 peers / collaborators interested in self-harm, suicide and mortality research across King's Health Partners.

The profile of SUMMIT has increased not just amongst the academic community but has been recognised as valuable by The South London and Maudsley Trust Wide Involvement Group. A carer has made a YouTube video hilighting the work of SUMMIT to mark World Suicide Prevention Day 2013: http://youtu.be/80yXDHIIdLQ
Year(s) Of Engagement Activity 2012,2013,2014,2015,2016
URL http://www.kcl.ac.uk/iop/depts/pm/events/SUMMIT.aspx
 
Description media - BBC Radio 4 Interview by Jenni Murray on Woman's Hour 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Talk sparked social media discussion, e.g. on Twitter, Facebook and intranet.

In interview with Jenni Murray I discussed the topic of "When someone needs help" - If you're concerned about the state of mind of someone close to you, what are the signs that could identify someone experiencing clinical depression rather than a low mood, or unhappiness? What should you do to support them, and what are your options if someone won't acknowledge they need help? Dr Rina Dutta is a consultant psychiatrist and academic at King's College London, and will join Jenni Murray to talk about noticing changes that could point to mental illness.
Year(s) Of Engagement Activity 2014
URL http://www.bbc.co.uk/programmes/b045y41n