Elsevier

The Lancet Psychiatry

Volume 3, Issue 3, March 2016, Pages 233-242
The Lancet Psychiatry

Articles
Suicide in perinatal and non-perinatal women in contact with psychiatric services: 15 year findings from a UK national inquiry

https://doi.org/10.1016/S2215-0366(16)00003-1Get rights and content

Summary

Background

Suicide in pregnant and postnatal women is an important cause of maternal death, but evidence to guide suicide prevention in this group is scarce. We aimed to compare the trend, nature, and correlates of suicide in perinatal and non-perinatal women in contact with psychiatric services.

Methods

We used 1997–2012 data from the UK National Confidential Inquiry into Suicides and Homicides by People with Mental Illness, which includes all suicides by people (age ≥10 years) who had been in contact with psychiatric services in the previous year. The study sample comprised all women who died by suicide in pregnancy or the first postnatal year (perinatal suicides), and all women in the same age range who died by suicide outside this period (non-perinatal suicides). We compared suicides among perinatal and non-perinatal women with logistic regression of multiply imputed data.

Findings

The study sample included 4785 women aged 16–50 years who died by suicide, of whom 98 (2%) died in the perinatal period. Of the 1485 women aged 20–35 years, 74 (4%) women died in the perinatal period. Over the course of the study, we recorded a modest downward trend in the mean number of women dying by suicide in the non-perinatal period (−2·07 per year [SD 0·96]; p=0·026), but not the perinatal period (−0·07 per year [0·37]; p=0·58). Compared with non-perinatal women, women who died by suicide in the perinatal period were more likely to have a diagnosis of depression (adjusted odds ratio [OR] 2·19 [95% CI 1·43–3·34]; p<0·001) and less likely to be receiving any active treatment (0·46 [0·24–0·89]; p=0·022) at the time of death. Women who died by suicide within versus outside the perinatal period were also more likely to be younger (crude OR −6·39 [95% CI −8·15 to −4·62]; p<0·0001) and married (4·46 [2·93–6·80]; p<0·0001), with shorter illness duration (2·93 [1·88–4·56]; p<0·001) and no history of alcohol misuse (0·47 [0·24–0·92]; p=0·027). There were no differences in service contact or treatment adherence.

Interpretation

In women in contact with UK psychiatric services, suicides in the perinatal period were more likely to occur in those with a depression diagnosis and no active treatment at the time of death. Assertive follow-up and treatment of perinatal women in contact with psychiatric services are needed to address suicide risk in this group.

Funding

Healthcare Quality Improvement Partnership and National Institute for Health Research.

Introduction

Suicide is an important cause of death during pregnancy and the first postnatal year, accounting for about 5–20% of maternal deaths in high-income countries,1, 2, 3, 4, 5, 6, 7 and 1–5% in low-income and middle-income countries.8 National inquiries have repeatedly called for improved detection and management of suicide risk in perinatal (pregnant and post-partum) women.1, 2 Suicide in women is rare, with an annual rate of about five to ten deaths per 100 000 population,9 and rarer still in the perinatal period, with a rate of one to five deaths per 100 000 livebirths in high-income settings.7, 10, 11 Prevention of such a rare outcome is challenging, and will probably require targeted intervention in high-risk women.12

Most women who die by suicide in the perinatal period have a known history of mental illness,1, 3, 7, 13 and, in Europe, 50–60% receive care from psychiatric services during their index pregnancy or postnatal period,1, 2, 7 which provides an opportunity for suicide prevention. Mental illness in the perinatal period has a distinct clinical presentation. For example, women are more likely to stop medication in the perinatal period than at other times,14, 15, 16 and are more likely to have abrupt onset, rapidly deteriorating psychosis in the postnatal period.17 Although most women have increased contact with health service during pregnancy, some might avoid services because of fear of stigma or child custody loss.13 These clinical differences might be reflected in a distinct suicide risk profile, but the risk profile of perinatal compared with non-perinatal suicides is poorly understood.

Previous studies of suicides in the perinatal period have several limitations: many focus on a single geographical area3, 18, 19, 20, 21 and examine a small number of correlates.22, 23 Studies based on maternal death inquiries have a brief reference period, examine only a few suicides at a given time, have insufficient data for psychiatric illness and service contact, and focus exclusively on the maternal population, and thus do not allow direct comparisons with suicides outside the perinatal period.1, 2, 24, 25 Women in contact with psychiatric services are an important high-risk group,6, 7, 23, 26 but few studies have examined their clinical presentation and treatment before suicide.

Research in context

Evidence before this study

We aimed to inform suicide prevention strategies in the perinatal period (during pregnancy and in the first postnatal year) by comparing the characteristics of women who died by suicide within and outside the perinatal period for women who had been in recent contact with UK psychiatric services. We searched MEDLINE for reviews and peer-reviewed articles published between Jan 1, 1990, and Oct 25, 2015, with evidence of the extent or risk factors for perinatal suicide in the general population and in psychiatric patients. Our search terms were (suicide or Suicide/) and (pregnancy or antenatal or postnatal or perinatal or maternal or Pregnancy/ or Perinatal Death/ or Perinatal Mortality/ or Maternal Mortality/). We also reviewed all available publications from the UK Confidential Enquiries into Maternal Deaths. Most studies used general population data and reported that suicide rates during pregnancy and the postnatal period were about two to three times lower than age-adjusted rates in non-perinatal women, in both high-income countries and low-income and middle-income settings. The proportion of maternal deaths attributable to suicide in most studies ranged from roughly less than 1% to 5% in low-income and middle-income countries (Fuhr DC, et al, 2014) and from 3% to 13% in high-income countries (as reported in studies from Europe, North America, and Australia). Few studies examined risk factors for maternal suicides. Reported risk factors included mental illness (present in 30–70% of maternal suicides), substance misuse, intimate partner violence, neonatal complications (particularly perinatal death), and medical comorbidity. Associations with age and socioeconomic status differed by setting and timing of suicide, with teenagers reported to have a higher risk of pregnancy suicide than women of other ages, especially in low-income and middle-income countries.

We identified one study of psychiatric patients, which investigated suicide rates in women admitted to a psychiatric hospital in the first postnatal year in Denmark over a 21 year period. This study reported that 0·9% of the women died by suicide in the first postnatal year (a 70 times higher risk than women in the general population) and 3·3% died by suicide over the whole study period (a 17 times higher risk). These findings suggest that the post-partum period, which is protective against suicide in the general population, is a high-risk period for women with severe post-partum mental illness. Qualitative evidence from maternal death inquiries suggest that mental illness is often undetected in perinatal women who die by suicide and, when detected, is often suboptimally managed, but these findings have not been investigated quantitatively. We did not find other evidence of the characteristics or risk profile of psychiatric patients who die by suicide in the perinatal period.

Added value of this study

This study is one of the largest case series of perinatal suicides among women in contact with psychiatric services, and uniquely compares sociodemographic and clinical characteristic of patients who died by suicide within and outside the perinatal period. We reported that women in contact with psychiatric services who died by suicide in the perinatal period were more likely to be young and married, and to have shorter mental illness duration and no history of alcohol misuse, than were those who died outside that period. Almost half of perinatal women had a diagnosis of depression (compared with a third of non-perinatal women) and a fifth had a diagnosis of schizophrenia or personality disorder; a quarter had a history of self-harm. A substantial minority were not receiving any active treatment or follow-up at the time of death. About three-quarters of women who died by suicide in the perinatal period used a violent suicide method (possibly indicating severe illness and serious intent).

Implications of all the available evidence

In the general population, suicide in the perinatal period is less common than at other times in a woman's life, but this protective effect might not apply to women in contact with psychiatric services (ie, those with severe mental illness), who might have a particularly high suicide risk in the first postnatal year. Women who die by suicide in the perinatal period are more likely to have a brief illness and depression diagnosis, and are less likely to be receiving active treatment, than are women who die by suicide outside this period. Clinicians should be aware that women with severe perinatal depression in particular are a group at risk of suicide who need careful monitoring and treatment.

To address some of these evidence gaps, we aimed to compare the characteristics of women who died by suicide within and outside the perinatal period for women who had been in recent contact with UK psychiatric services, and to compare suicide trends and methods in these two groups. More specifically, we aimed to test the hypotheses that women who died by suicide in the perinatal period were more likely to be non-adherent with medication and less likely to have been assessed as high risk by clinicians (on the basis of clinical differences between perinatal and non-perinatal patients).17, 27

Section snippets

Study design and study sample

We used 1997–2012 data from the UK National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). NCISH aims to identify all UK suicides by people aged 10 years and older who had been in contact with psychiatric services (in this context, any service provided by a secondary mental health-care provider) in the 12 months preceding the suicide. This contact can comprise outpatient, day-care, inpatient, or crisis home treatment care provided by one or more members of

Results

The Inquiry case series included 5135 deaths by suicide in women aged 16–50 years who were in contact with psychiatric services in the year preceding their death. After exclusion of 350 (7%) cases with missing data for whether suicide was in the perinatal period, the study sample included 4785 women who died by suicide, of whom 80 (2%) women died in the first postnatal year and 18 (<1%) women died during pregnancy. 98 (2%) of 4785 suicides in women aged 16–50 years and 74 (4%) of 1845 suicides

Discussion

Our findings show that roughly one in 50 suicides in women aged 16–50 years and one in 25 suicides in women aged 20–35 years were in the perinatal period. Over the course of the study, we recorded a modest downward trend in the number of women dying by suicide in the non-perinatal period, but not in the perinatal period. Compared with women who died by suicide outside the perinatal period, women who died by suicide in the perinatal period were more likely to have a diagnosis of depression with

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