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Suicide risk linked with clinical consultation frequency, psychiatric diagnoses and psychotropic medication prescribing in a national study of primary-care patients

Published online by Cambridge University Press:  21 September 2016

K. Windfuhr ,
D. While ,
N. Kapur ,
D. M. Ashcroft ,
E. Kontopantelis ,
M. J. Carr ,
J. Shaw ,
L. Appleby  and
R. T. Webb
K. Windfuhr
Affiliation:
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, University of Manchester, UK Centre for Mental Health and Safety, University of Manchester, UK
D. While
Affiliation:
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, University of Manchester, UK Centre for Mental Health and Safety, University of Manchester, UK
N. Kapur
Affiliation:
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, University of Manchester, UK Centre for Mental Health and Safety, University of Manchester, UK
D. M. Ashcroft
Affiliation:
Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School and NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, UK
E. Kontopantelis
Affiliation:
Centre for Health Informatics, Institute of Population Health, University of Manchester, UK
M. J. Carr
Affiliation:
Centre for Mental Health and Safety, University of Manchester, UK
J. Shaw
Affiliation:
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, University of Manchester, UK Centre for Mental Health and Safety, University of Manchester, UK
L. Appleby
Affiliation:
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, University of Manchester, UK Centre for Mental Health and Safety, University of Manchester, UK
R. T. Webb*
Affiliation:
Centre for Mental Health and Safety, University of Manchester, UK
*
*Address for correspondence: Dr R. Webb, Centre for Mental Health & Safety, Institute of Brain, Behaviour & Mental Healthm, Room 2.311, Jean McFarlane Building, Oxford Road, Manchester M13 9PL, UK. (Email: [email protected])
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Abstract

Background

Little is known about the precursors of suicide risk among primary-care patients. This study aimed to examine suicide risk in relation to patterns of clinical consultation, psychotropic drug prescribing, and psychiatric diagnoses.

Method

Nested case-control study in the Clinical Practice Research Datalink (CPRD), England. Patients aged ⩾16 years who died by suicide during 2002–2011 (N = 2384) were matched on gender, age and practice with up to 20 living control patients (N = 46 899).

Results

Risk was raised among non-consulting patients, and increased sharply with rising number of consultations in the preceding year [⩾12 consultations v. 1: unadjusted odds ratio (OR) 6.0, 95% confidence interval (CI) 4.9–7.3]. Markedly elevated risk was also associated with the prescribing of multiple psychotropic medication types (⩾5 types v. 0: OR 62.6, CI 44.3–88.4) and with having several psychiatric diagnoses (⩾4 diagnoses v. 0: OR 31.1, CI 19.3–50.1). Risk was also raised among patients living in more socially deprived localities. The confounding effect of multiple psychotropic drug types largely accounted for the rising risk gradient observed with increasing consultation frequency.

Conclusions

A greater proportion of patients with several psychiatric diagnoses, those prescribed multiple psychotropic medication types, and those who consult at very high frequency might be considered for referral to mental health services by their general practitioners. Non-consulters are also at increased risk, which suggests that conventional models of primary care may not be effective in meeting the needs of all people in the community experiencing major psychosocial difficulties.

Keywords

Epidemiologymental diseaseprimary carepsychosocial factorssuicide
Type
Original Articles
Information
Psychological Medicine , Volume 46 , Issue 16 , December 2016 , pp. 3407 - 3417
Copyright
Copyright © Cambridge University Press 2016 

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References

Appleby, L, Kapur, N, Shaw, J, Windfuhr, K, Williams, A, Hunt, IM, While, D, Flynn, S, Roscoe, A, Rodway, C, Ibrahim, S, Tham, S (2014). National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Annual report: England, Northern Ireland, Scotland and Wales 2014 (http://www.bbmh.manchester.ac.uk/cmhs/centreforsuicideprevention/nci/reports/Annualreport2014.pdf)Google Scholar
Cavanagh, JTO, Carson, AJ, Sharpe, M, Lawrie, SM (2003). Psychological autopsy studies of suicide: a systematic review. Psychological Medicine 33, 395–405.CrossRefGoogle ScholarPubMed
Chisholm, J (1990).The Read clinical classification. British Medical Journal 300, 1092.CrossRefGoogle ScholarPubMed
Clayton, M, Hills, D (1993). Statistical Models in Epidemiology. Oxford University Press: Oxford.Google Scholar
Congdon, P (2012). Assessing the impact of socioeconomic variables on small area variations in suicide outcomes in England. International Journal of Environmental Research and Public Health 10, 158–177.CrossRefGoogle ScholarPubMed
Copeland, KT, Checkoway, H, McMichael, AJ, Holbrook, RH (1977). Bias due to misclassification in the estimation of relative risk. American Journal of Epidemiology 105, 488–495.CrossRefGoogle ScholarPubMed
De las Cuevas, C, Penate, W, Sanz, EJ (2014). Risk factors for non-adherence to antidepressant treatment in patients with mood disorders. European Journal of Clinical Pharmacology 70, 89–98.CrossRefGoogle ScholarPubMed
de Vries, F, van Staa, TP, Bracke, MS, Cooper, C, Leufkens, HG, Lammers, JW (2005). Severity of obstructive airway disease and risk of osteoporotic fracture. European Respiratory Journal 25, 879–884.CrossRefGoogle ScholarPubMed
Didham, RC, McConnell, DW, Blair, HJ, Reith, DM (2005). Suicide and self-harm following prescription of SSRIs and other antidepressants: confounding by indication. British Journal of Clinical Pharmacology 60, 519–525.CrossRefGoogle ScholarPubMed
Dryden, R, Williams, B, McCowan, C, Themessi-Huber, M (2012). What do we know about who does and does not attend general health checks? Findings from a narrative scoping review. BMC Public Health 12, 723.CrossRefGoogle Scholar
FirstDataBank (2014). Multilex (http://fdbhealth.co.uk/solutions/multilex/).Google Scholar
Fleischhacker, WW, Uchida, H (2014). Critical review of antipsychotic polypharmacy in the treatment of schizophrenia. International Journal of Neuropsychopharmacology 17, 1083–1093.CrossRefGoogle ScholarPubMed
Fontanella, CA, Bridge, JA, Campo, JV (2009). Psychotropic medication changes, polypharmacy and the risk of early readmission in suicidal adolescent inpatients. Annals of Pharmacotherapy 43, 1939–1947.CrossRefGoogle ScholarPubMed
García Rodríguez, LA, Pérez Gutthann, S (1998). Use of the UK General Practice Research Database for pharmacoepidemiology. British Journal of Pharmacology 45, 419–425.Google ScholarPubMed
Gusmão, R, Quintão, S, McDaid, D, Arensman, E, Van Audenhove, C, Coffey, C, Värnik, A, Värnik, P, Coyne, J, Hegerl, U (2013). Antidepressant utlization and suicide in Europe: an ecological multi-national study. PLoS ONE 8, e66455.CrossRefGoogle Scholar
Haste, F, Charlton, J, Jenkins, R (1998). Potential for suicide prevention in primary care? An analysis of factors associated with suicide. British Journal of General Practice 48, 1759–1763.Google ScholarPubMed
Health and Social Care Information Centre (HSCIC) (2015). NHS UK Read Codes Clinical Terms Version 3, p. 3 (https://isd.hscic.gov.uk/trud3/user/guest/group/0/pack/9).Google Scholar
Herrett, E, Gallagher, AM, Bhaskaran, K, Forbes, H, Mathur, R, van Staa, T, Smeeth, L (2015). Data resource profile: clinical practice research datalink (CPRD). International Journal of Epidemiology 44, 827–836.CrossRefGoogle ScholarPubMed
Kontopantelis, E, Springate, D, Reeves, D, Ashcroft, DM, Valderas, JM, Doran, T (2014). Withdrawing performance indicators: retrospective analysis of general practice performance under UK quality and outcomes framework. British Medical Journal 348, g330.CrossRefGoogle ScholarPubMed
Linsley, KR, Schapira, K, Kelly, TP (2001). Open verdict v. suicide – importance to research. British Journal of Psychiatry 178, 465–468.CrossRefGoogle ScholarPubMed
Lintvedt, OK, Griffiths, KM, Sørensen, K, Østvik, AR, Wang, CE, Eisemann, M, Waterloo, K (2013). Evaluating the effectiveness and efficacy of unguided internet-based self-help intervention for the prevention of depression: a randomized controlled trial. Clinical Psychology and Psychotherapy 20, 10–27.CrossRefGoogle ScholarPubMed
Luoma, JB, Martin, CE, Pearson, JL (2002). Contact with mental health and primary care providers before suicide: a review of the evidence. American Journal of Psychiatry 159, 909–916.CrossRefGoogle ScholarPubMed
McLennan, D, Barnes, H, Noble, M, Davies, J, Garratt, E, Dibben, C (2011). The English Indices of Deprivation 2010. Department for Communities and Local Government: London (https://www.gov.uk/government/statistics/english-indices-of-deprivation-2010-technical-report).Google Scholar
Mojtabai, R, Olfson, M (2010). National trends in psychotropic medication polypharmacy in office-based psychiatry. Archives of General Psychiatry 67, 26–36.CrossRefGoogle ScholarPubMed
Morriss, R, Gask, L, Webb, R, Dixon, C, Appleby, L (2005). The effects on suicide rates of an educational intervention for front-line health professionals with suicidal patients (the STORM Project). Psychological Medicine 35, 957–960.CrossRefGoogle Scholar
Nock, MK, Borges, G, Bromet, EJ, Cha, CB, Kessler, RC, Lee, S (2008) Suicide and suicidal behavior. Epidemiologic Reviews 30, 133–154.CrossRefGoogle ScholarPubMed
Ohayon, MM, Lader, MH (2002). Use of psychotropic medication in the general population of France, Germany, Italy, and the United Kingdom. Journal of Clinical Psychiatry 63, 817–825.CrossRefGoogle ScholarPubMed
Park, J, Surles, R (2004). Using best practices to manage psychiatric medications under Medicaid. Psychiatric Services 55, 1227–1229.CrossRefGoogle Scholar
Pearson, A, Saini, P, Da Cruz, D, Miles, C, While, D, Swinson, N, Williams, A, Shaw, J, Appleby, L, Kapur, N (2009). Primary care contact prior to suicide in individuals with mental illness. British Journal of General Practice 59, 825–832.CrossRefGoogle ScholarPubMed
Peng, MM, Jick, H (2004). A population-based study of the incidence, cause, and severity of anaphylaxis in the United Kingdom. Archives of Internal Medicine 164, 317–319.CrossRefGoogle ScholarPubMed
Reilly, S, Planner, C, Hann, M, Reeves, D, Nazareth, I, Lester, H (2012). The role of primary care in service provision for people with severe mental illness in the United Kingdom. PLoS ONE 7, e36468.CrossRefGoogle ScholarPubMed
Rezaeian, M, Dunn, G, St Leger, S, Appleby, L (2005). The ecological association between suicide rates and indices of deprivation in English local authorities. Social Psychiatry and Psychiatric Epidemiology 40, 785–791.CrossRefGoogle ScholarPubMed
Rubio-Valera, M, Fernández, A, Luciano, JV, Hughes, CM, Pinto-Meza, A, Moreno-Küstner, B, Palao, DJ, Haro, JM, Serrano-Blanco, A (2012). Psychotropic prescribing in Catalonia: results from an epidemiological study. Family Practice 29, 154–162.CrossRefGoogle ScholarPubMed
Rutz, W, von Knorring, L, Wålinder, J (1989). Frequency of suicide on Gotland after systematic postgraduate education of general practitioners. Acta Psychiatrica Scandinavica 80, 151–154.CrossRefGoogle ScholarPubMed
Sachs, GS, Peters, AT, Sylvia, L, Grunze, H (2014). Polypharmacy and bipolar disorder: what's personality got to do with it? International Journal of Neuropsychopharmacology 17, 1053–1061.CrossRefGoogle Scholar
Smits, FTM, Brouwer, HJ, ter Riet, G, van Weert, HCP (2014). Epidemiology of frequent attenders: a 3-year historic cohort study comparing attendance, morbidity and prescription of one-year and persistent frequent attenders. BMC Public Health 9, 36.CrossRefGoogle Scholar
Springate, DA, Kontopantelis, E, Ashcroft, DM, Olier, I, Parisi, R, Chamapiwa, E, Reeves, D (2014). ClinicalCodes: an online clinical codes repository to improve the validity and reproducibility of research using electronic records. PLoS ONE 9, e99825.CrossRefGoogle Scholar
Wasserman, D, Rihmer, Z, Rujescu, D, Sarchiapone, M, Sokolowski, M, Titelman, D, Zalsman, G, Zemishlany, Z, Carli, V (2012). The European Psychiatric Association (EPA) guidance on suicide treatment and prevention. European Psychiatry 27, 129–141.CrossRefGoogle ScholarPubMed
WHO (2013). Mental Health Action Plan 2013–2020 (http://www.who.int/mental_health/publications/action_plan/en/).Google Scholar
Wright, AF (1996). Unrecognized psychiatric illness in general practice. British Journal of General Practice 46, 327–328.Google ScholarPubMed
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