Suicide by burning barbecue charcoal in England

Recent trends in an uncommon method of carbon monoxide suicide

PURPOSE

The most prevalent method of carbon monoxide (CO) suicide is inhalation of vehicle exhaust (VE). However, a new method of CO suicide has recently emerged involving charcoal burning (CB) in a confined space to produce fatal CO levels. This method has been reported from countries in Asia, associated with economic instability and media reporting of high-profile celebrity cases. The current study was undertaken to analyze rates and characteristics of CB suicides in South Australia (SA) for comparison with respect to their characteristics and scene, autopsy and toxicology findings.

METHODS

A search was undertaken for all intentional fatal carbon monoxide poisonings in SA between 2000 and 2019. Collected variables included age, sex, cause of death, location of death, decedent histories, scene, autopsy and toxicology findings and manner of death. Statistical analyses were performed using R (version 4.2.3).

RESULTS

There was a significant decrease in VE suicides (p < 0.05) and a significant increase in CB suicides (p < 0.001) over the 20-year period. Those who used CB were found to be, on average, between 1.5 and 15.8 years younger than those who used VE (p = 0.017). The risk factors for CB suicide included psychological/psychiatric conditions and financial problems, while VE suicides were associated with a history of physical problems and contact with the legal system. External and internal autopsy findings were consistent with the literature.

CONCLUSION

CB suicide is perceived to be widely accessible and painless and is therefore becoming a popular suicide method. Monitoring future trends will be important to determine whether intervention is required.

Spatial and temporal trends and risk factors for intentional carbon monoxide poisoning hospitalizations in England between 2002 and 2016

INTRODUCTION

Suicide and mental health disorders are a recognized increasing public concern. Most suicide prevention rely on evidence from mortality data, although suicide attempts are a better predictor for completed suicides. Understanding spatio-temporal patterns and demographic profiles of people at risk can improve suicide prevention schemes, including for carbon monoxide (CO) poisoning, a common method for gas-related suicides.

OBJECTIVE

Describe spatio-temporal patterns of intentional CO poisoning hospitalization rates in England between 2002 and 2016, and identify population sub-groups at risk.

METHODS

We used NHS Digital's Hospital Episode Statistics (HES) routinely collected data on hospital admissions for intentional CO poisoning. We estimated age-standardised rates (ASR) by year, gender and residential small-area characteristics, including rural/urban, deprivation and ethnic composition. Temporal trends were assessed through linear regression and joinpoint regression analysis. Regional differences were explored.

RESULTS

On average, we identified 178 hospital admissions for intentional CO poisoning per year. The ASR decreased substantially over the study period, particularly among males (average annual percent change of -7.8 % (95 % CI: -11.0; -4.6)), in comparison to 3.9 % (95%CI, -6.4; -1.4) among females. Most admissions (81 %) occurred in males. White men aged 35-44 years were particularly at risk. The ASR in London (0.08/100,000) was almost six times lower than in the South-West (0.47/100,000).

CONCLUSIONS

This study provides novel insights into attempted suicides by intentional CO poisoning. Further prevention interventions, targeting sub-groups at risk (i.e. white men in their 30s/40s), need to be developed and implemented to reduce the burden of suicides and of CO poisoning.

The evolution of charcoal-burning suicide: A systematic scoping review

INTRODUCTION

Suicide by charcoal burning has accounted for more than 100,000 deaths. It has become an increasingly common suicide method in Hong Kong since first reported in 1998, and it has spread into South Korea, Taiwan, Japan and other countries. This systematic scoping review aimed to explore current evidence on trends, risk factors, impact of media and prevention strategies for this suicide method, and to identify research gaps.

METHODS

A search for articles published from January 1998 to June 2021 was conducted through electronic databases (MEDLINE, EMBASE, SCOPUS and PsycINFO) with the keywords (suicide*) AND (charcoal). Articles describing prevalence, trends, characteristics, risk factors and prevention strategies of charcoal burning suicide deaths were included. Non-peer-reviewed articles, non-English articles, commentaries/editorials/letters, poster abstracts, reviews, meta-analyses and studies that documented only charcoal burning suicide attempters/survivors were excluded.

RESULTS

Eighty-eight studies were identified, most from East Asia. Charcoal burning suicide rates in Hong Kong, Taiwan and Japan has passed the peak, while continuing to increase in South Korea. Risk factors are changing and not static. Media appears to play an important role in triggering and spreading information. Restricting access to charcoal, and raising public awareness have been effective in the short term in preventing charcoal burning suicide, but there is little information on their long-term effectiveness or sustainability.

DISCUSSION

More research is required to update the development and dynamic changes of charcoal burning suicide and the contributing factors. The evidence from this review may assist in detecting and intervening early for future novel suicide methods.

Carbon monoxide suicide by charcoal-burning: a case report and review of the literature

Charcoal burning (CB) suicide is an old method that revived and has clearly become prevalent across several countries, as considered "soft" and "painless". This alarming spread is induced by the contagious effect of suicidal behaviors. Internet and suicide web forums may play, unfortunately, a crucial role in promoting this suicide's method. In this paper, we present the first documented case of CB suicide in Tunisia and probably in all African countries. Thereupon, we report a case of a young man suicide and we detail the forensic investigation findings. In order to prevent a potential epidemic spread, this form of suicide should require further attention not only in regions where it is already recognized but also in countries where it is not yet prevalent.

Suicide deaths by gas inhalation in Toronto: An observational study of emerging methods of suicide

BACKGROUND

Suicide death by gas inhalation has been the subject of global scientific interest due to a rapid increase in the use of helium and charcoal gas for suicide. These may be particularly amenable to means restriction strategies. There has been little scientific attention of this phenomenon in Canada.

METHODS

A review of coroner records was conducted for all suicide deaths in Toronto (1998-2015). Deaths were categorized as due to inhalational asphyxia by compressed gas (i.e. helium or nitrogen), charcoal burning or motor vehicle exhaust, with suicide deaths by other methods as a comparator. Demographic, clinical and suicide specific differences between decedents in these four categories were compared using chi-squared or ANOVA global test of significance with additional pairwise comparisons where appropriate. Secular trends were also examined.

RESULTS

Gas inhalational deaths accounted for 190 (4.7%) of all suicides in Toronto (n = 4062) over the study period and a higher proportion of males used compressed gas or motor vehicle exhaust gases than those who died by other methods (83.3% and 84.0% vs.69.7%, both p = 0.01). Comparing 1998-2003 to 2010-2015 there was a 1075% increase in deaths by helium (4 vs. 43 deaths) and a 533% increase in deaths by charcoal burning (3 vs. 16 deaths) although helium and charcoal burning deaths still accounted for only 4.2% of total suicides 2010-2015. Deaths by helium were more likely to be accompanied by the book "Final Exit" than those by non-inhalational methods (15% vs. 0.7%, p < 0.0001) while 13 of 14 people who died by charcoal burning whose ethnicity could be determined were Asian.

LIMITATIONS

Ethnicity and specific details of procurement of suicide methods were not systematically available in coroner records.

DISCUSSION

Suicide by inhalational asphyxia, particularly by compressed gases, has increased substantially over time in Toronto consistent with observations in other countries. Increased surveillance of these deaths, efforts to restrict access to these methods, and timely interventions including minimizing media reporting are all warranted.

A Public Health Approach in Responding to the Spread of Helium Suicide in Hong Kong

Abstract. Background: The use of the helium suicide method has been increasing in popularity in Hong Kong since 2012. We have learned a valuable lesson in curbing the spread of charcoal burning (CB) suicide in the past 15 years and hope to prevent the helium suicide method from taking off in the community. Aims: To document what actions have been taken to contain the spread of the helium suicide method and review the preliminary impact of these actions. Method: We adopted a public health approach by engaging stakeholders from multiple sectors, including the police force, the fire services department, coroners, pathologists, mass media, and online media outlets. Results: A monitoring system was established by compiling data extracted from news reports, coroners' reports, and police investigations. Risk and protective factors were identified. Intervention strategies were developed to strengthen protective factors and minimize risk factors. This novel suicide method has not spread as rapidly as the CB suicide method. The preliminary outcomes suggest our actions to be effective. Limitations: The count of helium suicides in 2015 might be low. The impacts of the interventions are only estimated and require additional empirical verifications. Conclusion: The public health approach of engaging multiple partners in the early phase of a potential epidemic can be a good guide to meeting the challenges posed by any new suicide methods that emerge in the future.

Media effects on suicide methods: A case study on Hong Kong 1998-2005

Background

Previous studies have suggested that mass media’s reports of new suicide methods will increase suicides using the same method. The same pattern seems not to apply to a conventional suicide method, unless it was used by a celebrity.

Objective

1) to examine media effects on both new and non-new suicide methods during 1998 and 2005 in Hong Kong (HK), when a new method by burning charcoal (CB suicide) was spreading in the region. 2) to examine how CB competed with non-CB methods in terms of media coverage and “recruiting” suicidal persons in the socio-economic context.

Methods

A self- and mutual- exciting process model was fitted to the data, adjusting for divorce rate, unemployment rate, and property price index. Breaking the whole period into onset, peak, and post-peak stages, the model was fitted again to examine the differences.

Results

Comparable copycat effects were found on both CB and non-CB suicide news. The only cross-method media effects were found in the onset stage when non-CB suicide news showed suppressing effect on CB suicides. CB suicides reported a significant self-excitation effect. A higher divorce rate and lower property price index were associated with significantly more suicides incidences and more suicide news.

Conclusions

The emerging of CB suicide method did not substitute media coverage of non-CB suicide in HK. Media effects in this case were not limited to new suicide method or celebrity suicide. The effects were further fueled by adverse socio-economic conditions.

Information Accessibility of the Charcoal Burning Suicide Method in Mainland China

Background

There has been a marked rise in suicide by charcoal burning (CB) in some East Asian countries but little is known about its incidence in mainland China. We examined media-reported CB suicides and the availability of online information about the method in mainland China.

Methods

We extracted and analyzed data for i) the characteristics and trends of fatal and nonfatal CB suicides reported by mainland Chinese newspapers (1998–2014); ii) trends and geographic variations in online searches using keywords relating to CB suicide (2011–2014); and iii) the content of Internet search results.

Results

109 CB suicide attempts (89 fatal and 20 nonfatal) were reported by newspapers in 13 out of the 31 provinces or provincial-level-municipalities in mainland China. There were increasing trends in the incidence of reported CB suicides and in online searches using CB-related keywords. The province-level search intensities were correlated with CB suicide rates (Spearman’s correlation coefficient = 0.43 [95% confidence interval: 0.08–0.68]). Two-thirds of the web links retrieved using the search engine contained detailed information about the CB suicide method, of which 15% showed pro-suicide attitudes, and the majority (86%) did not encourage people to seek help.

Limitations

The incidence of CB suicide was based on newspaper reports and likely to be underestimated.

Conclusions

Mental health and suicide prevention professionals in mainland China should be alert to the increased use of this highly lethal suicide method. Better surveillance and intervention strategies need to be developed and implemented.

Searching for Suicide Methods

Abstract. Background: Helium gas suicides have increased in England and Wales; easy-to-access descriptions of this method on the Internet may have contributed to this rise. Aims: To investigate the availability of information on using helium as a method of suicide and trends in searching about this method on the Internet. Method: We analyzed trends in (a) Google searching (2004–2014) and (b) hits on a Wikipedia article describing helium as a method of suicide (2013–2014). We also investigated the extent to which helium was described as a method of suicide on web pages and discussion forums identified via Google. Results: We found no evidence of rises in Internet searching about suicide using helium. News stories about helium suicides were associated with increased search activity. The Wikipedia article may have been temporarily altered to increase awareness of suicide using helium around the time of a celebrity suicide. Approximately one third of the links retrieved using Google searches for suicide methods mentioned helium. Conclusion: Information about helium as a suicide method is readily available on the Internet; the Wikipedia article describing its use was highly accessed following celebrity suicides. Availability of online information about this method may contribute to rises in helium suicides.

The association of trends in charcoal-burning suicide with Google search and newspaper reporting in Taiwan: a time series analysis

PURPOSE

Some East/Southeast Asian countries have experienced a rapid increase in suicide by charcoal burning over the past decade. Media reporting and Internet use were thought to contribute to the epidemic. We investigated the association between method-specific suicide incidence and both Internet search volume and newspaper reporting in Taiwan.

METHOD

Weekly data for suicide, suicide-related Google search volume, and the number of articles reporting suicide in four major newspapers in Taiwan during 2008-2011 were obtained. Poisson autoregressive regression models were used to examine the associations between these variables.

RESULTS

In the fully adjusted models, every 10 % increase in Google searches was associated with a 4.3 % [95 % confidence interval (CI) 1.1-7.6 %] increase in charcoal-burning suicide incidence in the same week, and a 3.8 % (95 % CI 0.4-7.2 %) increase in the following week. A one-article increase in the United Daily was associated with a 3.6 % (95 % CI 1.5-5.8 %) increase in charcoal-burning suicide in the same week. By contrast, non-charcoal-burning suicide was not associated with Google search volume, but was associated with the Apple Daily's reporting in the preceding week.

CONCLUSIONS

We found that increased Internet searches for charcoal-burning suicide appeared to be associated with a subsequent increase in suicide by this method. The prevention of suicide using emerging methods may include monitoring and regulating online information that provides details of these methods as well as encouraging Internet service providers to provide help-seeking information.

Suicide by gases in England and Wales 2001-2011: evidence of the emergence of new methods of suicide

BACKGROUND

Increases in suicide deaths by gassing, particularly carbon monoxide poisoning from burning barbecue charcoal, have occurred in many parts of East Asia and resulted in rises in overall suicide rates in some countries. Recent trends in gas poisoning suicides outside Asia have received little attention.

METHODS

We analysed suicides by gassing in England and Wales (2001-2011) using national suicide mortality data enhanced by free text searching of information sent by coroners to the Office for National Statistics (ONS). We conducted specific searches for suicides involving barbecue charcoal gas, helium, and hydrogen sulphide. We analysed coroners' records of eight people who used helium as a method of suicide, identified from systematic searches of the records of four coroners.

RESULTS

Gassing accounted for 5.2% of suicide deaths in England and Wales during 2001-2011. The number of gas suicides declined from 368 in 2001 to 174 by 2011 (a 53% reduction). The fall was due to a decline in deaths involving car exhaust and other sources of carbon monoxide. There was a rapid rise in deaths due to helium inhalation over the period, from five deaths in the two year period 2001-2002 to 89 in 2010-2011 (a 17-fold increase). There were small rises in deaths involving hydrogen sulphide (0 cases in 2001-2002 versus 14 cases in 2010-2011) and barbecue charcoal gas (1 case in 2001-2002 versus 11 cases in 2010-2011). Compared to individuals using other methods, those suicides adopting new types of gas for suicide were generally younger and from more affluent socioeconomic groups. The corones' records of four of the eight individuals dying by helium inhalation whose records were reviewed showed evidence of Internet involvement in their choice of method.

LIMITATIONS

We were not able to identify the source of carbon monoxide (car exhaust or barbecue charcoal) for over 50% of cases.

CONCLUSION

Increases in helium inhalation as a method of suicide have partially offset recent decreases in suicide by the use of car exhaust. Public health measures are urgently needed to prevent a potential epidemic rise in the use of helium similar to the recent rises in charcoal burning suicides in East Asia.

Predicting duration of mechanical ventilation in patients with carbon monoxide poisoning: a retrospective study

PURPOSE

Patients with severe carbon monoxide (CO) poisoning may develop acute respiratory failure, which needs endotracheal intubation and mechanical ventilation (MV). The objective of this study was to identify the predictors for duration of MV in patients with severe CO poisoning and acute respiratory failure.

MATERIALS AND METHODS

This is a retrospective observational study of 796 consecutive patients diagnosed with acute CO poisoning that presented to the emergency department. Patients who received MV were divided into 2 groups: the early extubation (EE) consisting of patients who were on MV for less than 72 hours and the nonearly extubation (NEE) consisting of patients who were on MV for more than 72 hours. Demographic and clinical data of the two groups were extracted for analysis.

RESULTS

The intubation rate of all CO-poisoned patients was 23.4%. A total of 168 patients were enrolled in this study. The main source of CO exposure was intentional CO poisoning by charcoal burning (137 patients). Positive toxicology screening result was found in 104 patients (61.9%). The EE group had 105 patients (62.5%). On arriving at the emergency department, high incidence of hypotension; high white blood cell count; and elevation of blood urea nitrogen, creatinine, aspartate aminotransferase, alanine aminotransferase, creatine kinase, and troponin-I levels were statistically significant in the NEE group (P < .05). Positive toxicology screening result was statistically significant in the EE group (P < .05). In a multivariate analysis, elevation of troponin-I level was an independent factor for NEE (odds ratio, 1.305; 95% confidence interval, 1.024-1.663; P = .032). Positive toxicology screening result was an independent factor for EE (odds ratio, 0.222; 95% confidence interval, 0.101-0.489; P = .001).

CONCLUSIONS

A positive toxin screen predicts extubation within the first 72 hours for patients with severe CO poisoning and acute respiratory failure. On the other hand, elevation of initial troponin-I level is a predictor for a longer duration of MV.

Epidemiological study of self-immolation at khatamolanbia hospital of zahedan

Background:

Self-immolation is a high risk behavior and a way of life termination. Self-immolation, as the most painful of all forms of suicide, is not a common form of suicide in European countries. However, it is highly prevalent in developing countries particularly in Asia and Africa.

Objectives:

The aim of this study was to assess the rate and leading factors of self-immolation and gender, geographical distribution, and social norms of affected patients referred to Khatamolanbia Hospital of Zahedan from March 2010 to May 2012.

Materials and Methods:

This descriptive and objective-based study was cross-sectional and retrospective with 750 burn patients; 315 of them had attempted self-immolation and most of them died. The data collection tool was a two partite questionnaire consisting of 17 questions (8 questions about personal details and 9 questions about self-immolation factors).

Results:

350 self-immolations resulting in death were reported in this study; these subjects were 16-25 years old, 67.25% female, 63.55% elementary school education, 74.20% married, 69.10% housewife, 61.05% resident of Saravan, 93.35% oil burns, 72.30% middle and low social class, 90.20% burn over 68%, 20% psychiatric illness history and being treated with antidepressants, 73.25% verbal and physical violence before burning, and 100% of the burnings took place inside a house and usually during the afternoon.

Conclusions:

Due to the high rate of self-immolations in this area, solutions for improvement of life quality and social norms should be reviewed and implemented.

Regional changes in charcoal-burning suicide rates in East/Southeast Asia from 1995 to 2011: a time trend analysis

BACKGROUND

Suicides by carbon monoxide poisoning resulting from burning barbecue charcoal reached epidemic levels in Hong Kong and Taiwan within 5 y of the first reported cases in the early 2000s. The objectives of this analysis were to investigate (i) time trends and regional patterns of charcoal-burning suicide throughout East/Southeast Asia during the time period 1995-2011 and (ii) whether any rises in use of this method were associated with increases in overall suicide rates. Sex- and age-specific trends over time were also examined to identify the demographic groups showing the greatest increases in charcoal-burning suicide rates across different countries.

METHODS AND FINDINGS

We used data on suicides by gases other than domestic gas for Hong Kong, Japan, the Republic of Korea, Taiwan, and Singapore in the years 1995/1996-2011. Similar data for Malaysia, the Philippines, and Thailand were also extracted but were incomplete. Graphical and joinpoint regression analyses were used to examine time trends in suicide, and negative binomial regression analysis to study sex- and age-specific patterns. In 1995/1996, charcoal-burning suicides accounted for <1% of all suicides in all study countries, except in Japan (5%), but they increased to account for 13%, 24%, 10%, 7%, and 5% of all suicides in Hong Kong, Taiwan, Japan, the Republic of Korea, and Singapore, respectively, in 2011. Rises were first seen in Hong Kong after 1998 (95% CI 1997-1999), followed by Singapore in 1999 (95% CI 1998-2001), Taiwan in 2000 (95% CI 1999-2001), Japan in 2002 (95% CI 1999-2003), and the Republic of Korea in 2007 (95% CI 2006-2008). No marked increases were seen in Malaysia, the Philippines, or Thailand. There was some evidence that charcoal-burning suicides were associated with an increase in overall suicide rates in Hong Kong, Taiwan, and Japan (for females), but not in Japan (for males), the Republic of Korea, and Singapore. Rates of change in charcoal-burning suicide rate did not differ by sex/age group in Taiwan and Hong Kong but appeared to be greatest in people aged 15-24 y in Japan and people aged 25-64 y in the Republic of Korea. The lack of specific codes for charcoal-burning suicide in the International Classification of Diseases and variations in coding practice in different countries are potential limitations of this study.

CONCLUSIONS

Charcoal-burning suicides increased markedly in some East/Southeast Asian countries (Hong Kong, Taiwan, Japan, the Republic of Korea, and Singapore) in the first decade of the 21st century, but such rises were not experienced by all countries in the region. In countries with a rise in charcoal-burning suicide rates, the timing, scale, and sex/age pattern of increases varied by country. Factors underlying these variations require further investigation, but may include differences in culture or in media portrayals of the method. Please see later in the article for the Editors' Summary.

Regional changes in charcoal-burning suicide rates in East/Southeast Asia from 1995 to 2011: a time trend analysis

BACKGROUND

Suicides by carbon monoxide poisoning resulting from burning barbecue charcoal reached epidemic levels in Hong Kong and Taiwan within 5 y of the first reported cases in the early 2000s. The objectives of this analysis were to investigate (i) time trends and regional patterns of charcoal-burning suicide throughout East/Southeast Asia during the time period 1995-2011 and (ii) whether any rises in use of this method were associated with increases in overall suicide rates. Sex- and age-specific trends over time were also examined to identify the demographic groups showing the greatest increases in charcoal-burning suicide rates across different countries.

METHODS AND FINDINGS

We used data on suicides by gases other than domestic gas for Hong Kong, Japan, the Republic of Korea, Taiwan, and Singapore in the years 1995/1996-2011. Similar data for Malaysia, the Philippines, and Thailand were also extracted but were incomplete. Graphical and joinpoint regression analyses were used to examine time trends in suicide, and negative binomial regression analysis to study sex- and age-specific patterns. In 1995/1996, charcoal-burning suicides accounted for <1% of all suicides in all study countries, except in Japan (5%), but they increased to account for 13%, 24%, 10%, 7%, and 5% of all suicides in Hong Kong, Taiwan, Japan, the Republic of Korea, and Singapore, respectively, in 2011. Rises were first seen in Hong Kong after 1998 (95% CI 1997-1999), followed by Singapore in 1999 (95% CI 1998-2001), Taiwan in 2000 (95% CI 1999-2001), Japan in 2002 (95% CI 1999-2003), and the Republic of Korea in 2007 (95% CI 2006-2008). No marked increases were seen in Malaysia, the Philippines, or Thailand. There was some evidence that charcoal-burning suicides were associated with an increase in overall suicide rates in Hong Kong, Taiwan, and Japan (for females), but not in Japan (for males), the Republic of Korea, and Singapore. Rates of change in charcoal-burning suicide rate did not differ by sex/age group in Taiwan and Hong Kong but appeared to be greatest in people aged 15-24 y in Japan and people aged 25-64 y in the Republic of Korea. The lack of specific codes for charcoal-burning suicide in the International Classification of Diseases and variations in coding practice in different countries are potential limitations of this study.

CONCLUSIONS

Charcoal-burning suicides increased markedly in some East/Southeast Asian countries (Hong Kong, Taiwan, Japan, the Republic of Korea, and Singapore) in the first decade of the 21st century, but such rises were not experienced by all countries in the region. In countries with a rise in charcoal-burning suicide rates, the timing, scale, and sex/age pattern of increases varied by country. Factors underlying these variations require further investigation, but may include differences in culture or in media portrayals of the method. Please see later in the article for the Editors' Summary.

A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England

Objectives

To carry out a programme of linked research studies aimed at improving the management of self-harm, reducing the incidence of suicide and providing reliable data to evaluate the impact of theNational Suicide Prevention Strategy for England(2002).

Methods

There were four research streams: (1) we studied inquest records from 12 coroners and Ministry of Justice data to assess the accuracy of official suicide statistics; (2) we used Office for National Statistics mortality statistics, data from the Multicentre Study of Self-harm in England, national liver unit data, prescription data and patient interviews to assess (a) the impact of paracetamol (acetaminophen) pack size restrictions (1998), (b) the impact of withdrawal of co-proxamol in 2007 and (c) the relative toxicity in overdose of commonly used antidepressants; (3) we carried out 3-month audits of self-harm management in 32 hospitals to investigate variations between hospitals and the impact of management on repeat self-harm; and (4) we developed and piloted letter-based contact interventions aimed at reducing self-harm.

Key findings

(1) Between 1990 and 2005, the proportion of researcher-defined suicides given a verdict of suicide by the 12 coroners studied decreased by almost 7%, largely because of the increased use of misadventure/accident verdicts for deaths thought, on clinical review, to be suicides. Use of narrative verdicts increased markedly. Coroners who gave more narrative verdicts also gave fewer suicide verdicts, and geographical variations in the use of narrative verdicts appeared to distort reliable assessment of small-area differences in suicide rates. 2(a) UK legislation to reduce pack sizes of paracetamol was followed by a 43% reduction in number of deaths and a 61% reduction in registrations for liver transplantation over the next 11 years. Paracetamol overdoses were often impulsive and some were influenced by media (including the internet); sales outlets appeared mostly to be adhering to sales guidance. Smaller pack sizes of paracetamol for sale in Ireland compared with England did not result in a smaller number of tablets being taken in overdose. There was no clear evidence of an effect of the legislation on prescribing of non-steroidal anti-inflammatory drugs, nor on resulting gastrointestinal bleeds. 2(b) Withdrawal of co-proxamol from use in the UK resulted in approximately 600 fewer deaths than predicted between 2005 and 2010 based on previous trends, with no evidence of substitution by poisoning with other analgesics. 2(c) Of the tricyclic antidepressants, dosulepin and doxepin had the greatest toxicity. Citalopram was more toxic than other selective serotonin reuptake inhibitors. (3) There was marked variation between hospitals in the management of self-harm; effects of this variation on patient outcomes were unclear, although psychosocial assessment may have been associated with reduced repetition. Levels of specialist assessment remained static between 2001–2 and 2010–11, but service quality appeared to improve. (4) Findings of two pilot randomised controlled trials suggested that, although it would be feasible to scale up these interventions to full trials, these interventions might have low generalisability and be of limited benefit to patients.

Conclusion

Within the context of the strengths and limitations of the individual studies, this research programme has made significant additions to the evidence base related to suicide and self-harm prevention in the UK.

Study registration

A pilot study of a contact and information based intervention to reduce repeat self-harm; ISRCTN65171515.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.