Louis Appleby’s research while affiliated with University of Manchester and other places

Background An improved understanding of the factors associated with self-harm in young people who die by suicide can inform suicide prevention measures. Aims To describe sociodemographic and clinical characteristics and service utilisation related to self-harm in a national sample of young people who died by suicide. Method We carried out a descriptive study of self-harm in a national consecutive case series ( N = 544) of 10- to 19-year-olds who died by suicide over 3 years (2014–2016) in the UK as identified from national mortality data. Information was collected from coroner inquest hearings, child death investigations, criminal justice system and National Health Service serious incident reports. Results Almost half (49%) of these young people had harmed themselves at some point in their lives, a quarter (26%) in the 3 months before death. Girls were twice as likely as boys to have recent self-harm (40 v . 20%; P < 0.001). Compared to the no self-harm group, young people with recent self-harm were more likely to have a mental illness diagnosis (63 v. 23%; P < 0.001); misused alcohol (19 v. 9%; P = 0.07); experienced physical, sexual or emotional abuse (17 v. 3%; P < 0.01); and recent life adversity (95 v. 75%; P < 0.001). Furthermore, they were more likely to be in contact with mental health services (60 v. 10%), or emergency departments or general physicians for a mental health condition (52 v. 10%) in the 3 months before death. Conclusions Presentation to services in young people who self-harm is an important opportunity to intervene through comprehensive psychosocial assessment and treatment of underlying conditions.

Background Suicide is the leading cause of preventable death in prisons. Deaths from suicide in prison are significantly, and persistently, elevated compared to those living in the community. Psychological therapies have been shown to be a potentially effective means of alleviating suicidal thoughts, plans and behaviours, but patients located in prison often have no access to evidence-based psychological interventions targeting suicide. The objectives of this programme of research are to investigate the clinical and cost effectiveness of a new psychological therapy programme delivered to male prisoners at risk of suicide. Methods The PROSPECT trial is a two-armed single blind, pragmatic, randomised controlled trial and will recruit a target sample size of 360 male prisoners, identified as at-risk of suicide, across 4 prisons in the North of England. Participants will be randomised to receive a psychological talking therapy (Cognitive Behavioural Suicide Prevention, CBSP) plus treatment as usual, or treatment as usual alone. Co-primary outcomes (Suicide Ideation and Suicide Behaviours), as well as related secondary outcomes, will be assessed at baseline and at 6-months follow-up. An intention to treat analysis will be conducted with primary stratification based on prison site and lifetime history of suicide attempt (yes/no). A nested qualitative process evaluation will investigate the nature and context in which the intervention is delivered, with specific focus upon the facilitators and barriers to the implementation of the therapy within prisons. Discussion The key outputs from this trial will be to determine whether a psychological therapy for suicidal prisoners is clinically and cost effective; and to generate a project implementation platform that identifies how best to implement the new intervention across the broader prison estate. Trial registration ISRCTN (reference ISRCTN14056534 https://www.isrctn.com/ISRCTN14056534; 24th September 2021). Registration confirmed prior to participant recruitment commencing. Modifications to protocol are listed on the study website at ISRCTN.

Background Tackling methods of suicide and limiting access to lethal means remain priority areas of suicide prevention strategies. Although mental health services are a key setting for suicide prevention, no recent studies have explored methods used by mental health patients. Aims To investigate associations between main suicide methods and social, behavioural and clinical characteristics in patients with mental illness to inform prevention and improve patient safety. Method Data were collected as part of the National Confidential Inquiry into Suicide and Safety in Mental Health. We examined the main suicide methods of 26 766 patients in the UK who died within 12 months of contact with mental health services during 2005–2021. Associations between suicide methods and patient characteristics were investigated using chi-square tests and univariate and multivariate logistic regression. Results Suicide methods were associated with particular patient characteristics: hanging was associated with a short illness history, recent self-harm and depression; self-poisoning with substance misuse, personality disorder and previous self-harm; and both jumping and drowning with ethnic minority groups, schizophrenia and in-patient status. Conclusions A method-specific focus may contribute to suicide prevention in clinical settings. Hanging deaths outside of wards may be difficult to prevent but our study suggests patients with recent self-harm or in the early stages of their illness may be more at risk. Patients with complex clinical histories at risk of suicide by self-poisoning may benefit from integrated treatment with substance use services. Environmental control initiatives are likely to be most effective for those at risk of jumping or drowning.

Background Suicide-related internet use (SRIU), defined as internet use related to one's own feelings of suicide, can be both a risk and protective factor, especially for isolated individuals. Despite its influence on suicidality, clinicians face challenges in assessing SRIU because of the private nature of internet usage. Current recommendations on enquiring about SRIU in a clinical setting concern mostly young people. AimsTo address the gap in understanding SRIU among patients of all ages, this study aims to explore mental health clinicians’ experiences, attitudes and beliefs regarding enquiring about SRIU, as well as the risks and benefits it presents in the assessment and management of patients. Finally, the study aims to establish the role SRIU potentially plays in the assessment and management of patients. Method Twelve clinicians practising at secondary mental health services in England participated in interviews. Thematic analyses were used for data interpretation. ResultsClinicians who participated in interviews rarely initiate discussions on SRIU with their patients despite considering this an important factor in suicidality. Age of both patients and clinicians has the potential to influence enquiry into SRIU. Clinicians recognise the potential benefits of patients finding supportive online communities but also express concerns about harmful and low-quality online content related to suicide. Conclusions Integrating SRIU enquiry into standard clinical practice, regardless of the patient's age, is an important step towards comprehensive patient care. Broader training for clinicians on enquiring about online behaviours is essential to mitigate potential risks and harness the benefits of SRIU in mental health patients.

Psychological autopsies refer to retrospective interviews between researchers and informants who were close to a person who died by suicide, to explore and better understand the circumstances and contributing factors to that suicide. However, several issues persist with psychological autopsy as a methodology. We assessed the academic literature regarding psychological autopsies and extracted key themes about methodological limitations and weaknesses. The aim was to formulate recommendations and present suggestions for future methodology that would protect the benefits of psychological autopsy, particularly the personal narratives, while addressing methodological limitations. A literature review of nine relevant healthcare research databases yielded twenty-two relevant papers. Each of these publications were reviewed and themes regarding methodological limitations of psychological autopsies were identified and collated. Limitations identified from the review included issues of validity and reliability, lack of standardisation, biases, control variables, cultural considerations, ethics, and data handling. New limitations regarding cultural nuance, modern communication channels, and 'invisible informants' were identified. Recommendations for the future development of the psychological autopsy method include embracing modern communication methods and 'invisible informants', cultural intersections, safeguarding of reliability and validity, and the use of feasibility trials. The emphasis remains upon collating the raw narratives at the core of these interviews which make the psychological autopsy such a unique and insightful tool.

Background Suicide-related internet use (SRIU) has been shown to be linked to suicide. However, there is limited research on SRIU among mental health patients, who are at 4 to 7 times increased risk of suicide compared to the general population. This study aims to address this gap by exploring the prevalence of SRIU among mental health patients who died by suicide in the UK and describing their characteristics.

Background People under the care of mental health services are at increased risk of suicide. Existing studies are small in scale and lack comparisons. Aims To identify opportunities for suicide prevention and underpinning data enhancement in people with recent contact with mental health services. Method This population-based study includes people who died by suicide in the year following a mental health services contact in Wales, 2001–2015 (cases), paired with similar patients who did not die by suicide (controls). We linked the National Confidential Inquiry into Suicide and Safety in Mental Health and the Suicide Information Database – Cymru with primary and secondary healthcare records. We present results of conditional logistic regression. Results We matched 1031 cases with 5155 controls. In the year before their death, 98.3% of cases were in contact with healthcare services, and 28.5% presented with self-harm. Cases had more emergency department contacts (odds ratio 2.4, 95% CI 2.1–2.7) and emergency hospital admissions (odds ratio 1.5, 95% CI 1.4–1.7), but fewer primary care contacts (odds ratio 0.7, 95% CI 0.6–0.9) and out-patient appointments (odds ratio 0.2, 95% CI 0.2–0.3) than controls. Odds ratios were larger in females than males for injury and poisoning (odds ratio: 3.3 (95% CI 2.5–4.5) v. 2.6 (95% CI 2.1–3.1)). Conclusions We may be missing existing opportunities to intervene, particularly in emergency departments and hospital admissions with self-harm presentations and with unattributed self-harm, especially in females. Prevention efforts should focus on strengthening routine care contacts, responding to emergency contacts and better self-harm care. There are benefits to enhancing clinical audit systems with routinely collected data.