Severe mental illness

Welcome to the ZSA Facts for Action series

This page provides key information to explain what severe mental illness is and will help build your understanding of its complexity as a risk factor to suicide. 

Contents:

1. What is serious mental illness?
2. Why is SMI important to consider in the context of suicide prevalence?
3. Prevalence of SMI
4. ZSA Suicide Prevention Resource Map - key takeaways
5. Life course of SMI
6. Predisposing factors of SMI
7. Consequences of SMI
8. Impact of COVID-19
9. National guidelines for practice
10. Key approaches
11. Case studies
12. ZSA Suicide Prevention Resource Map - related indicators
13. References

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What is Serious Mental Illness (SMI)?

'Serious Mental Illness’ or ‘Severe Mental Illness’ (SMI) refers to a psychological disorder that severely impairs a person’s ability to function in everyday tasks and activities (Public Health England, 2018).[1]

Even though many enduring and complex mental health illnesses are ‘serious’, exactly which mental illnesses ‘SMI’ refers is unclear. Public Health England (PHE)[1] lean towards defining SMI as a diagnosis of schizophrenia and bipolar disorder, where as the National Institute for Health and Care Excellence (NICE) widen this definition to encompass diagnoses of schizotypal and delusional disorders and severe depressive episodes with or without psychotic episodes (NICE, 2016).[2]

This confusion has practical implications on practice as well as data collection and analysis. For example, PHE’s data collection on people with SMI includes personality disorder in addition to schizophrenia, other psychoses and bipolar disorder. Whereas data collected through the Mental Health Clustering Tool (MHCT) (NHSE/I) distinguishes between psychoses and personality disorder (clusters 10-17 and 8, respectively).

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Why is SMI important to consider in suicide prevalence?

People with an SMI are at high risk of self-harm and dying by suicide (McManus et al., 2016).[3] A comprehensive research review found that the risk of people with schizophrenia and other psychoses dying by suicide was 5-7%, with some studies finding this figure to be higher at 10% (Girgis, 2020). [4] Overall, people that develop schizophrenia and related psychoses are 12 times more likely to complete suicide compared to the general population (Girgis, 2020).[4] 

How people experience psychosis is also key in their suicide risk. Research has found that positive symptoms of psychosis, such as hallucinations, delusions and disordered thinking often experienced in first-time episodes have been found to increase suicidal risk. Whereas negative symptoms, such as flat mood, lack of motivation, social withdrawal and self-neglect have been found to decrease this risk (Huang et al., 2017).[5] Other studies support this by finding that the first-episode and the year following presents the highest risk of suicide (Girgis, 2020),[4] leaving people 60% more at risk of dying by suicide than those experiencing later phases (Nordentoft, et al., 2004).[6] This highlights the important role of specialised Early Intervention in Psychosis (EIP) services in early detection, providing effective treatment interventions and ultimately preventing suicide incidences in the early stages of psychosis (Marshall & Rathbone, 2011).[7] 

People with bipolar disorder are also at very high risk of suicide, with 25-50% of people with bipolar experiencing at least one suicide attempt (Jamison, 2000),[8] and 11-19% of people completing suicide (da Silva Costa at al., 2015).[9]  Research has found that 70% of suicide attempts occur during episodes of severe depression (Dalton et al., 2003).[10]

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Prevalence of SMI

Generally across England, less than 1% of the population are living with an SMI (National Institute of Mental Health, 2019).[11] Survey data collected by the Office for National Statistics in 2014 revealed that this has remained broadly stable over time (ONS, 2016).[12] However, there have been some more recent findings that this could be increasing (National Institute of Mental Health, 2019).[11] Reasons for this could be improved identification and better access to treatment.

Research has found that even though SMI prevalence does not significantly differ between men and women, it varies depending on factors such as ethnicity, population density and social deprivation (Kirkbride et al., 2012).[13] This is supported by research finding that psychoses is more common in ethnic minority groups (Halvorsrud, 2019).[14] Studies have also found that SMI is more prevalent in the most deprived areas (PHE, 2018).[1]

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ZSA Suicide Prevention Resource Map – key takeaways

Our Suicide Prevention Resource Map identifies that according to Clinical Commissioning Group (CCG) data there is approximately a 10% higher prevalence of SMI predominantly across London, Birmingham, North England, North West England, South England and the South East coasts of England in comparison to national prevalence across England as whole. This disparity is likely to be associated to variation in experience of economic, health and social factors which not only contribute to a person’s predisposition to developing an SMI, but also the inequalities they face as a consequence of living with and recovering from an SMI.

These regions also broadly reflect the highest annual prevalence of prescribing of antipsychotic drugs, with a relatively more dispersed pattern for the provision of antipsychotic depot injections.

For more information please see Facts for Action for Suicide Prevention Resource Map.

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Life course of SMI

SMIs are most likely to develop in teenage and early adult years, with it being more common and more likely to develop earlier in men than women (National Institute of Mental Health, 2019; Ochoa et al., 2012; Arnold, 2003).[11][15][16]

As these early adult years are a key period of social development, men are likely to experience significant detrimental impacts later in life as a result of SMI (Häfner, 2003).[17] Men are also more likely than women to misuse substances and disengage in treatment leaving them more likely to relapse (Arnold, 2003; Häfner, 2003). [16][17] However research has found that women with bipolar still face considerable life course challenges such as being more likely than men to experience other additional mental and physical health conditions (Ochoa et al., 2012).[15] 

Generally, experience of recovery from SMI varies. Some people respond well and can greatly improve with medical and psychological interventions, whereas others experience a more disrupted recovery with persisting and recurrent symptoms, requiring prolonged input from mental health services. Early intervention initiatives including contact with EIP services are vital as have been shown to result in the best recovery outcomes for these individuals (Santestedban-Echarri et al., 2017).[18]

The nature of different SMIs also influences life course experiences. For example with schizophrenia and psychoses, even though positive symptoms may have been successfully treated by antipsychotics and routine depot injections, negative symptoms often remain (National Collaborating Centre for Mental Health, 2014).[19] These negative symptoms have a lasting impact on cognitive processes making it harder for these individuals to engage in recovery services and occupational activities (Nuechterlein et al., 2011).[20] Recurrent symptoms of bipolar and their relation to other health and social factors (e.g. co-existing disorders, low socio-economic status and adherence to medication), these of which can disrupt recovery (Alloy, Nusslock & Boland, 2015).[21]

Even though experiencing SMI can impact many areas of life, an important part of recovery is to regain a sense of identity, whereby an SMI diagnosis is one part of a person, rather than their defining feature.

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Predisposing factors of SMI

There is no single cause of SMI but it is thought to be a combination of biological and social factors (e.g. childhood experiences, environment, brain chemistry, genetics). Whilst biological factors play an important part and leave a person vulnerable to develop an SMI, social factors have been widely noted as a key contributor to their onset. For example, people with SMIs are likely to have experienced distressing events in early childhood and with stressful events in adulthood (e.g. relationship breakdown, bereavement). These experiences are significant in the predisposition of developing an SMI. Socioeconomic factors such as living in poverty and in areas of deprivation have a cyclical relationship with both increasing risk of developing an SMI through social stress, and are a high risk consequence of living with an SMI (PHE, 2018; Mental Health Foundation, 2016).[1][22] 

Adverse childhood events

This brings to light the role that Adverse Childhood Experiences (ACEs) have in developing an SMI. Examples of ACEs are exposure to violence, abuse and growing up in an unstable environment, such as within a family with substance misuse or mental health problems. Not only have these individuals enduring severe stress as a child, their ability to develop psychological strategies to manage and cope with stress later in life is often stunted. There is a wealth of evidence that ACEs are linked to developing an SMI, with a strong connection to developing psychosis (Garno et al., 2005; Varese et al., 2012).[23][24]

Substance misuse

Substance misuse is also an important factor in developing schizophrenia and psychosis, as chemical interactions can trigger initial symptoms of those with a predisposition for the condition. This is a common occurrence as substances are often used as an accessible coping mechanism to manage stress. This is supported by research finding that the prevalence of substance misuse among people with SMIs is over 50% (Hunt et al., 2019).[25] 

By working to address and reduce the impact of these underlying causes we can help prevent the development of SMIs.

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Consequences of SMI

Social inequalities 

People with SMI face a range of social inequalities. Research has also found that people experiencing SMI is most prevalent areas of low income and deprivation (National Institute of Mental Health, 2019; Kirkbride, 2017),[11][26] and is commonly associated with low levels of employment (PHE, 2018).[1]  Research has demonstrated that financial strain and unemployment has a negative impact upon overall wellbeing including a person’s self esteem, social identity, meaningful purpose, social isolation and their uncertainty about the future (Russell, O-Connell & McGinnity, 2009a).[27] These factors have serious implications as studies have found unemployment to be linked to high rates of suicide (Nordt et al., 2015).[28] 

Research has also found that people with SMI have a high risk of social drop-out, including withdraws from society, education, employment and daily tasks and activities (Langan, 2014).[29] Reasons for this include the problems that people with SMI have in forming new relationships and functioning in job-related activities as a result of cognitive deficits (Pinkham, 2014).[30] Stigma and discrimination against people with SMIs also has severe consequences in terms of social exclusion with opportunities to get back into education and work being limited (Thornicroft & Sunkel, 2020).[31] 

A recent publication of the National Clinical Audit of Psychosis (NCAP) found that only 31% took up employment support (Royal College of Psychiatrists, 2020).[32] Therefore, more needs to be to done to support people with SMI get into supported employment and education programs (Pothier et al., 2019).[33]

These issues are likely to be compounded for people with co-morbidity with substance misuse.  Research has found they are at higher risk of homelessness, incarceration and have fewer social supports and financial resources (Khokhar et al., 2018).[34] Substance misuse is also more likely to trigger a relapse in symptoms and result in admission to hospital, this being double the rate of those experience psychoses alone (Menezes et al., 1996).[35] 

Ethnic minorities with SMIs are also disproportionately impacted by social inequalities (Kirkbride et al., 2017),[26] this of which is partially reflected by an over representation in crisis and inpatient mental health services (Baker, 2020).[36] Older adults are also an at risk population as are often forgotten about and face social inequalities as a result (Royal College of Psychiatrists, 2018).[37]

Again, it is worth emphasising that these social inequalities are not just a consequence of having an SMI but contribute to perpetuating poor psychological wellbeing and mental health.

Health access inequalities 

People with SMI also face stark physical health inequalities, with these individuals dying on average 15-20 years than the general population (PHE, 2018).[1] Two-thirds of these premature deaths are caused by chronic physical conditions such as coronary heart disease, type 2 diabetes and respiratory disease.  People with SMI also have higher rates of health related risk behaviours (e.g. obesity and smoking), this being double of those of the general population (Davies, 2013).[38] If these health issues are identified early and are appropriately treated, premature death is ultimately preventable (PHE, 2018).[1]

People living with a SMI also experience co-morbidity with other mental health disorders.  Schizophrenia and psychoses are commonly experienced alongside a number of other mental health conditions, such as depression and anxiety, post-traumatic stress disorder and substance misuse (NHS, 2019).[39] Bipolar disorder can also be comorbid commonly associated with anxiety disorders, substance misuse and behavioural disorders (Parker, 2010).[40]

People with SMI often experience a significant delay in gaining access to mental health services and receiving appropriate treatment (Dagani et al., 2017).[41] This has severe long-term consequences on recovery and contributes to the high mortality rate for this population group with one-third dying by suicide (PHE, 2018).[1] Reasons for this delay have been suggested to be due to difficulties specific SMI identification (e.g. dual nature of bipolar disorder symptoms), clinicians being cautious in committing to an often stigmatising illnesses, or services facing challenges in coordinating appropriate treatment. 

As a result, people with SMI have the highest rates of A&E attendances and form the highest proportion of people in inpatient units of all types, as detained under the Mental Health Act (PHE, 2018).[1] The inequality gap is widened by proven effective NICE treatments not being consistently available, finding that only 49% received CBT for psychosis and 21% took up family interventions (Royal College of Psychiatrists, 2020).[32]

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Impact of COVID-19

Research found that over the COVID-19 lockdown there was an increase in poorer mental health across the general population (Understanding Society, 2020).[42] People with pre-existing mental health illnesses, physical health conditions and those that live in deprived areas were highlighted as key risk groups. These correlated with people SMI as a population group and therefore are likely to experience significant deterioration in mental health. Loneliness and isolation was found to be a key contributory theme (Samaritans, 2020),[43] this of which is already a central challenge for people with SMI.   

This has resulted in an increase in referrals to crisis services, whilst there is a fall in referrals from primary care to secondary mental health services.

Due to the high likelihood of people with SMI having pre-existing health conditions, these individuals are more vulnerable to poorer health outcomes if they contract COVID-19 (NHS, 2020).[44] There is also some recent evidence to suggest that people with SMI who are being treated with clozapine, a type of antipsychotic, they are at a higher risk of contracting COVID-19 (Govind et al., 2020).[45] There is also emerging evidence that has suggested that people with COVID-19 may be at risk of developing neuropsychiatric symptoms including psychosis (Ferrando et al., 2020).[46]

Economic deprivation and unemployment

Studies conducted during the COVID-19 pandemic have already found that there has been a large increase in the proportion of people living in deep poverty (Understanding Society, 2020).[42] Research forecasting the future impact of COVID-19 has also highlighted that there will be higher levels of economic adversity and housing problems as a result of job losses (NHS Confederation, 2020).[47] This is likely to increase the prevalence of SMI within these areas as has been identified as a risk factor.  People with SMI already face challenges gaining employment opportunities, but these are likely to be intensified with more limited opportunities in the economic landscape. 

As a key point, research also highlights the impact that increased unemployment will have on suicide rates (NHS Confederation, 2020).[47]  The economic crisis in 2008 illustrates this with rates worsening from 2009 and peaking in 2012 (Nordt et al., 2015).[28]

Substance use

Research conducted by the Centre for Mental Health during the pandemic found that there was a surge in alcohol use in order to cope with increased stress (Centre for Mental Health, 2020).[48] The impact this has on people with SMI is likely to be significant.  During a time when support from family, friends and professions is limited, alcohol use is an accessible way of coping with distressing feelings.  Research has found that substance misuse is robustly related to non-adherence to treatment and poorer outcomes (Margolese et al., 2004; Verdoux et al., 2005).[49][50]. For more information, see our Facts for Action series on Substance Misuse.

Experiences at home

Research during the pandemic has found increased incidences of domestic violence and single parents reporting increased distress and worsened relationships with their children (Centre for Mental Health, 2020).[48]. Children from an minority ethnic background have also reported an increase in suicidal thoughts and incidences of self-harm during the pandemic (XenZone, 2020).[51] Research by NHS England and NHS Improvement estimate that despite the increase in demand for children and young people’s services, referrals have dropped by 30-40% (Health and Social Care Committee, 2020).[52] The reported increase in distressing experiences as a result of the COVID-19 lockdowns and the lack accessible support during this time, leaves children at a higher risk of developing an SMI in adulthood, especially within families already struggling with other social stressors (Varese et al., 2012; Garno et al., 2005).[24] [23]

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National guidelines for practice

Broad picture

The Five Year Forward View for Mental Health published by the NHS in 2016 outlined a long-term transformation of mental health services (NHS, 2016).[53] The plan detailed changes that would improve outcomes for people with SMI. These included early intervention care packages people experiencing psychosis for the first time, meeting physical health needs and increasing access to psychological therapies (NICE, 2018).[54] The role of ACEs in SMI was also highlighted, recommending individualised trauma-informed care.  Emphasis was also placed on providing support for self-harm and substance misuse, effective rapid crisis response, and increasing the role of peer support for recovery (NICE, 2019).[55]

The importance of Individual Placement and Support (IPS) programmes were recognised in improving the high rates of unemployment in people with an SMI and the difficulties they face gaining employment opportunities and thriving in them.

NICE guidelines

The following NICE guidelines and accompanying quality standards are directly relevant to the assessment and treatment of schizophrenia and related psychoses and bipolar disorder.

• Psychosis and schizophrenia in adults: prevention and management (Clinical Guideline CG178).[56]
• Psychosis and schizophrenia in adults (Quality Standard QS80)[57]
• Bipolar disorder: assessment and management (Clinical Guideline CG185)[58]
• Bipolar disorder in adults (Quality Standard QS95)[59]

SMI treatment is delivered primarily through Community Mental Health Teams (CMHTs) and EIP services.  However, crisis and inpatient services also often treat those experiencing relapse or require intensive multi-disciplinary input.  

BPS guidelines

The British Psychological Society provide a series of guidelines to help clinicians work in a psychologically informed way.  As part of this, the BPS work alongside NICE in developing guidelines for the treatment of mental health disorders, including SMI. The BPS have also produced reports that have contributed to making fundamental changes to the way SMI is viewed by society, and subsequently managed and treated within mental health services. 

BPS reports:

• Understanding Psychosis and Schizophrenia – Why people sometimes hear voices, believe things that others find strange, or appear out of touch with reality, and what can help (Cooke, 2017).[60]
• Understanding Bipolar Disorder – Why people experience extreme mood states, and what can help (Mansell et al., 2010).[61]

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Key approaches

Recovery approach

As clearly outlined by the BPS, treatment for SMI has moved away from solely treating SMI symptoms with medical interventions, to an approach that considers the role of psychological and social factors in contributing to developing an SMI and how they can inform recovery from SMI. This shift is reflected in the recovery model which draws attention to addressing social inequalities faced by those with SMI. 

Recovery services take a person-centered and collaborative approach to work alongside the person and provide tailored input to their specific needs (NICE, 2020).[62] The recovery approach also focuses on building upon a person’s strengths, increasing their confidence and encouraging hope for the future. 

To address issues of social exclusion, the recovery model also helps people re-engage in their communities, seek peer support, find work, build relationships and engage in meaningful leisure activities. A recent survey by Rethink Mental Illness revealed that much more needs to be done to support people to find suitable housing, receive appropriate benefits, gain employment and volunteer placements, and be involved in community initiatives and activities (Rethink Mental Illness, 2019).[63]

"When it comes to supporting people severely affected by mental illness, making sure people are able to access high quality treatment in a timely manner is one vital part of the picture. But we also need to think about all the other factors that shape our mental health: our housing, our jobs, our financial situation, and our support networks."

Rethink Mental Illness – Building Communities that Care Report (2019)

Examples of how recovery models are being successfully used can be found below.

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Case studies

Examples of excellent practice in line with national guidance and key change approaches for SMI are included here.

Individual Placement and Support (IPS) Programmes

IPS is a support service that uses evidence based strategies to help people experiencing SMIs to gain employment (Bond, Drake & Campbell, 2016).[64] Gaining employment can help people regain financial security, re-engage in their community, and build a greater sense of purpose and wellbeing. IPS programmes also help reduce the demand for primary and secondary mental health services.

IPS programmes offer people with individualised tailored support from an Employment Specialist. Employment Specialists offer occupational advice, help people work towards their goals and aspirations, and help them overcome barriers they face. They also help people develop the skills needed to gain and sustain employment. As IPS programmes are often integrated into community mental health services, the person’s care team will be made aware of their progress, whilst the Employment Specialists are able to gain an informed view of how best to support the person. 

For more information about IPS programmes for people with SMI, see NHS England's website.

Examples of IPS programmes:

• Northamptonshire Healthcare NHS Foundation Trust – Offers an IPS for service-users under the care of the early intervention and forensic teams as part of a wider Planned Care and Recovery (PCART) service.  For more information, visit the Northamptonshire Healthcare website.  
• Central and North West London NHS Foundation Trust (CNWL) - Set up an IPS in 2004, CNWL has since supported over 2000 people into paid employment in a range of industries.  In 2010 they became apart of the Centre for Mental Health IPS Centre of Excellence Programme.  For more information, visit Central and North West London NHS Trust website.

Examples of other employment support initiatives:

• Dorset Healthcare NHS Foundation Trust – The Occupational Therapy team within forensic services set up the Bright Bean Café which aimed to build a sense of community within the hospital and help service-users learn skills that will help them gain employment.  Equipment and barista training was provided with the support of another local business, Full Circle Coffee Company.  For more information, Dorset Health Care University NHS Foundation Trust.

Examples of broader community based initiatives:

• Life Rooms are an excellent example of a community based initiative established by Mersey Care NHS Foundation Trust. It is underpinned by the recovery approach and acknowledges that a range of social, economic and environmental factors play a vital role in maintaining good mental health and wellbeing. The Life Rooms function as part of the ‘social prescribing’ model helping people with SMI who live in disadvantaged communities (Hassan et al., 2020).[65] 

Social prescribing is a way for healthcare professionals to refer people to a range non-clinical services in their local area. This model aims to address people’s needs in a holistic way and enables helps people take control of their own recovery and ongoing wellbeing (Kings Fund, 2018).[66] These services help people develop a range of occupational based skills, daily living skills and engage in meaningful leisure activities, helping them integrate back into their communities and live fulfilling lives away from mental health services. 

The Life Rooms offer is broad and includes:

• IPS workers
• Peer support workers
• Recovery learning
• IT and life skills development training
• Facilitated access to debt, housing, legal, employment support and help with other issues through third sector providers such as the Citizens Advice Bureau (CAB). 
• Meaningful occupation opportunities – Life Rooms peer workers are employed as part of NHS and therefore have internal staff access to jobs, training, rights and support.

To find out more about applying the Life Rooms model, please visit our Case study library.

Crisis cafés

In partnership with Mind, Crisis cafés offer people (18+) in the community a safe place where they can receive support if they are in crisis or need help with their mental health.  Crisis cafés are also often open outside of normal working hours and so offer an alternative option to visiting A&E, helping to relieve pressure from emergency services.

Examples of Crisis cafés:

• Mind in Bedfordshire, Luton and Milton Keynes
• Mind in Northamptonshire (Hope Centre and The Sanctuary)
• Mind in Bexley
• Surrey and Borders Partnership NHS Foundation Trust (Virtual Safe Haven)

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ZSA Suicide Prevention Resource Map - related indicators

Direct

• SMI Prevalence
• Perinatal: Post-partum psychosis
• Perinatal: Severe depressive illness
• Depression prevalence
• Annual prescribing of antipsychotic drugs per 100,000 population
• Annual prescribing of antipsychotic depot injections per 100,000 population

Indirect

• Cognitive behavioural therapy for psychosis (CBTp)
• Family Intervention
• Employment and education programme
• Physical health screening and interventions
• Carer-focused education and support
• Gap in employment rate (%) for people with mental health conditions
• Index of Multiple Deprivation - Local Authority Score

For more specific indicators for services for people with SMI, see Facts for Action series for Community Mental Health services, Early Intervention for Psychosis services and crisis response services.

* All data from NHS Benchmarking Network projects is subject to change dependent upon permissions being received from provider organisations to have their data included in the map. The information reported reflects the data available as at 10/03/2021.

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References

[1] Public Health England (2018). Severe mental illness (SMI) and physical health inequalities: briefing. Available at: https://www.gov.uk/government/publications/severe-mental-illness-smi-physical-health-inequalities/severe-mental-illness-and-physical-health-inequalities-briefing 

[2] NICE (2016). Coexisting severe mental illness and substance misuse: community health and social care services.  Available at: https://www.nice.org.uk/guidance/ng58/chapter/recommendations#severe-mental-illness 

[3] McManus S, Hassiotis A, Jenkins R, Dennis M, Aznar C, Appleby L. (2016). ‘Chapter 12: suicidal thoughts, suicide attempts and self-harm,’ in McManus S, Bebbington P, Jenkins R, Brugha T. (eds) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. Available at: https://webarchive.nationalarchives.gov.uk/20180328130852tf_/http://content.digital.nhs.uk/catalogue/PUB21748/apms-2014-suicide.pdf/ 

[4] Girgis, R. (2020). The neurobiology of suicide in psychosis: A systematic review. Journal of psychopharmacology, 34(8), 811-819. Available at: https://journals.sagepub.com/doi/abs/10.1177/0269881120936919 

[5] Huang, X., Fox, K., Ribeiro, J. & Franklin, J. (2017). Psychosis as a risk factor for suicidal thoughts and behaviors: A meta-analysis of longitudinal studies. Cambridge University Press, 48(5), 765-776. Available at: https://www.cambridge.org/core/journals/psychological-medicine/article/abs/psychosis-as-a-risk-factor-for-suicidal-thoughts-and-behaviors-a-metaanalysis-of-longitudinal-studies/D9A10D628C7D2B08E88A58707D9C8197

[6] Nordentoft, M., Laursen, T., Agerbo, E., Qin, P., Høyer, E. & Mortensen, P. (2004). Change in suicide rates for patients with schizophrenia in Denmark, 1981-97: nested case-control study. British Medical Journal, 329, 261. Available at: https://www.bmj.com/content/329/7460/261.full 

[7] Marshall, M. & Rathbone, J. (2011). Early intervention for psychosis. Cochrane Database of Systematic Reviews, 6, CD004718. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004718.pub3/full 

[8] Jamison, K. (2000). Suicide and Bipolar Disorder. Journal of Clinical Psychiatry, 61 Suppl 9, 57-51. Available at: https://www.researchgate.net/publication/12490748_Suicide_and_Bipolar_Disorder

[9] Da Silva Costa, L. et al. (2015). Risk factors for suicide in bipolar disorder: A systematic review. Journal of Affective Disorders, 170, 237-254. Available at: https://doi.org/10.1016/j.jad.2014.09.003 

[10] Dalton, E., Cate-Carter, T., Mundo, E., Parikh, S., Kennedy, J. (2003). Suicide risk in bipolar patients: the role of co-morbid substance use disorders. Bipolar Disorder, 5(1), 58-61. Available at: https://doi.org/10.1034/j.1399-5618.2003.00017.x 

[11] National Institute of Mental Health (2019). Mental Health Information: Serious Mental Illness.  Available at: https://www.nimh.nih.gov/health/statistics/mental-illness.shtml#:~:text=Serious%20mental%20illness%20(SMI)%20is,or%20more%20major%20life%20activities.

[12] Office for National Statistics (2016). Adult Psychiatric Morbidity Survey 2014. Available at: https://files.digital.nhs.uk/pdf/q/3/mental_health_and_wellbeing_in_england_full_report.pdf 

[13] Kirkbride, J., Errazuriz, A., Croudace, T., Morgan, C., Jackson, D., Boydell, J., et al. (2012). Incidence of schizophrenia and other psychoses in England, 1950–2009: A systematic review and meta-analyses. PloS one, e31660. Available at: https://pubmed.ncbi.nlm.nih.gov/22457710/ 

[14] Halvorsrud, K., Nazroo, J., Otis, M., Brown Hajdukova, E. & Bhui, K.. (2019). Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: A systematic review and new meta-analyses for non-affective and affective psychoses. Social Psychiatry and Psychiatric Epidemiology, 54, 1311-1223. Available at: https://doi.org/10.1007/s00127-019-01758-y 

[15] Ochoa, S., Usall, J., Cobo, J., Labad, X. & Kulkarni, J. (2012). Gender differences in schizophrenia and first-episode psychosis: A comprehensive literature review. Schizophrenia Research and Treatment, 916298. Available at: https://pubmed.ncbi.nlm.nih.gov/22966451/ 

[16] Arnold, L. (2003). Gender differences in bipolar disorder. Psychiatric Clinics of North America, 26(3), 595-620. Available at: https://doi.org/10.1016/S0193-953X(03)00036-4 

[17] Häfner, H., Maurer, K., Löffler, W., an der Heiden, W., Hambrecht, M. & Schultze-Lutter, F. (2003). Modeling the Early Course of Schizophrenia. Schizophrenia Bulletin, 29(2), 325-340. Available at: https://doi.org/10.1093/oxfordjournals.schbul.a007008 

[18] Santesteban-Echarri, O., Paino, M., Rice, S., González-Blanch, C., McGorry, P., Gleeson, J., et al. (2017). Predictors of functional recovery in first-episode psychosis: A systematic review and meta-analysis of longitudinal studies. Clinical Psychology Review, 58, 59-75. Available at: https://doi.org/10.1016/j.cpr.2017.09.007 

[19] National Collaborating Centre for Mental Health (2014). Psychosis and Schizophrenia in Adults: The NICE Guideline on Treatment and Management. Available at: https://www.nice.org.uk/guidance/cg178/evidence/full-guideline-490503565 

[20] Nuechterlein, K., Subotnik, K., Green, M., Ventura, J., Asarnow, R., Gitlin, M., Yee, M., Gretchen-Doorly, D., Mintz, J. (2011). Neurocognitive predictors of work outcome in recent-onset schizophrenia. Schizophrenia. Bulletin, 37(2), 33-40. Available at: https://doi.org/10.1093/schbul/sbr084 

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Content reviewed and updated 13/09/22