A study of violent death and mental illness in a catchment area population

Abstract

The relationship between suicide and mental illness is well established. A majority of suicides show signs of mental illness at the time of their death and suicide is a major cause of mortality in the mentally ill. Psychiatrists are interested in identifying patients at highest risk of suicide. The degree of proof required for a suicide verdict results in the self-inflicted violent death rate of patients being underestimated. A review is made of the ways in which the relationship between violent death mortality and mental illness has been studied. The main part of this study is based on a total population of 412 residents of a defined catchment area who died potentially self-inflicted violent deaths in England or Wales in the period 1974-1981. Suicide verdicts were returned on 59% of the deaths, 31% were found to be accidental and 10% undetermined. Another 21 residents were murdered. Results are presented descriptively in terms of when, where and how the deaths occurred, and of the lifetime history of pyschiatric referral; and quantitatively in terms of mortality rates. Remarkable similarities were found between the verdict groups. At least half of each group had been referred to a psychiatrist and a third admitted to a mental hospital. Two thirds of the patients in each group were recent patients having a psychiatric contact less than 365 days before the event leading to their death and a fifth were current patients when they killed themselves. A verdict of suicide was returned on the majority of patients with a psychotic illness but a non-suicide verdict was returned on a majority of patients with personality, drug and alcohol related disorders, and on females with schizophrenia. The excess mortality of these recent patients is presented in terms of rates and relative risk for the three verdict groups and for different diagnostic groups, and the risk of violent death attributable to severe mental illness calculated. The risk of all forms of self-inflicted death was significantly higher for recent patients than for other residents in the same population. An `epidemic' of inpatient deaths followed the opening of a new DGH Psychiatric Unit. A comparison of the total number of patients who killed themselves in the 3 year periods before and after the change in service shows no significant increase in the total number of recent patient deaths in the under 65 agegroup compared with the over 65 agegroup whose service was unchanged. A large increase was found in the number of deaths of residents never referred to the psychiatric service. The characteristics of the inpatients are descibed. Highest rates of violent death for both suicides and non-suicides were associated with not being married, not working and living alone. Referred and non-referred victims, and suicides and non-suicides among patients could not be differentiated in terms of social variables but the social characteristics of the patients varied with diagnostic group. A brief description of the homicide victims and assailants is given.

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