Alcohol and drug misuse mean Scots are almost twice as likely to kill or take their own life compared to people living in England and Wales.
The findings by The University of Manchester's National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI) also show that the number of mental health patients committing homicide or suicide was proportionately much higher in Scotland.
The 'Lessons for Mental Health Care in Scotland' report, commissioned by the Scottish Government, blames these higher death rates north of the border on alcohol and drug consumption, both in the general population and among mental health patients.
The NCI examined all suicides and homicides in the general population in Scotland, as well as those committed by people who had sought help from mental health services, and compared them to its findings for England and Wales.
Suicide rates in Scotland equated to 18.7 per 100,000 of the population, compared to 10.2 per 100,000 in England and Wales, while homicide rates north of the border were 2.12 per 100,000 people compared to 1.23 per 100,000 in England and Wales. The north-south divide was highest among teenagers, the report found.
"In the time covered by the study -- six years for suicides and five years for homicide -- there were about 5,000 suicides and 500 murders in Scotland," said Louis Appleby, Professor of Psychiatry and NCI Director. "However, the Inquiry found that only 28% of the people who took their own life and 12% of killers had recently been mental health patients.
"There has been a welcome recent fall in the suicide rates among the general Scottish population but, despite this, the most striking feature of rates north of the border is how much higher they are than in England and Wales.
"Similarly, the homicide rate in Scotland is substantially higher than in England and Wales. However, in contrast to suicide rates, national homicide rates are high because of particularly high rates in certain areas of the country, namely Glasgow and Clyde and Argyll."
In Scotland, as in England, Wales and elsewhere, the report found that homicide is a crime committed primarily by young men against young men. The team found that, in the cases they studied, alcohol and drugs had often been taken and the weapon was usually a knife or other sharp object.
"Drugs and knives are a dangerous mix, so policy response to these deaths should focus on alcohol and drug abuse in young people and on the carrying of knives by young men," said Professor Appleby.
"The rise in homicide rates in recent years is the result of an increase in killings by young people, mainly men under 25 years, but most are not mentally ill. Therefore, a public health approach to homicide would target alcohol and drug use before mental health illness.
"Alcohol and drug misuse runs through these findings and it appears to be a major contributor to risk in mental health care and broader society. The findings suggest that alcohol and drugs lie behind Scotland's high rates of suicide and homicide and the frequency with which they occur as antecedents in our report are striking."
Of the 1,373 patient suicides in the report, there was a history of alcohol misuse in 785 cases, an average of 131 deaths per year; a history of drug misuse was witnessed in 522 cases, or 87 deaths per year.
Of the 58 patient homicides observed, 41 had a history of alcohol abuse and 45 had drug misuse. Among all perpetrators, whether patients or not, drug and alcohol dependence were the most common diagnoses. In both suicide and homicide, most were not under the care of addiction services.
"Our findings support the view that alcohol and drugs are the most pressing mental health problems in Scotland and mental health services can play their part," said Professor Appleby, who is based in Manchester's Faculty of Medical and Human Sciences.
"They must ensure that front-line clinical staff are skilled and confident in assessing and managing misuse; that they develop dedicated services for dual diagnosis, and that they establish close links with addiction teams."
The report also makes the following recommendations for clinical care:
- specialist community mental health teams providing an outreach service for patients who are at risk of losing contact with care
- early follow-up following hospital discharge, requiring joint risk management by in-patient and community teams
- more intensive supervision of patients recently admitted to hospital
- removal of ligature points from in-patient wards
- prevention of absconding from wards through improvements in the ward environment and tighter control of exits
- careful assessment of risk during periods of leave leading up to hospital discharge
- improved mental health services for young people, providing better access and early intervention
- positive clinical attitudes to the management of risk as part of a more understanding dialogue with the public
- examination of reasons for imprisonment of offenders with severe mental illness.
The NCI report, 'Lessons for Mental Health Care in Scotland', will be published on June 16, at a launch event in Edinburgh.
Please note the report refers to 'homicides', the killing of one person by another, rather than 'murders', which is premeditated homicide. In Scotland, homicide includes two different court verdicts -- homicide and culpable homicide. Culpable homicide is similar to manslaughter in England.
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