ArticlesImplementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: a cross-sectional and before-and-after observational study
Introduction
Prevention of suicide is an international health priority.1, 2 Many people who die by suicide have a psychiatric disorder at the time of death: most commonly mood disorders and alcohol or drug misuse.3 Mental health services could have an important part to play in reducing the risk of suicide.4, 5, 6 Service-related risk factors for suicide identified in previous studies include poor continuity of care,7 scarcity of well developed mental health services in the community,8 short length of inpatient stay,9 reduction of care at final appointment before death,10 and missed appointments with services.11 Most studies of the relation between service interventions and suicide rate are limited by small sample sizes, short follow-up periods after intervention, cross-sectional rather than prospective designs, and infrequent collection of data on service-related variables. Few studies have been national in scope. The aspects of service provision that might be most effective in prevention of suicide are unclear.
Our aim was to examine the relation between provision of mental health services and national suicide rates. We focused on key service recommendations made by the National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness—a project that aims to monitor suicide and ultimately improve the quality of mental health care in the UK. We had four specific objectives: to examine the implementation of key service recommendations by providers of mental health services in England and Wales with time; to examine the cross-sectional association between the number of recommendations implemented and suicide rate across providers; to measure suicide rates before and after implementation within providers; and to investigate the effect of individual recommendations on suicide risk in specific clinical subgroups.
Section snippets
Data collection
The organisation of health care varies across different nations of the UK so for ease and clarity we use the generic term “mental health services” throughout this report. In 2002, 2004, and 2006, all mental health services provided by the National Health Service (NHS) in England and Wales were asked to complete a service provision survey. The few private providers and Regional Secure (Forensic) Units were excluded. The questionnaire was based on previous NCI recommendations;12 it included items
Results
From 1997 to 2006, the NCI recorded 12 881 suicides (12 098 in England, 783 in Wales) within 91 mental health services accounting for 26% of 50 437 suicides in England and Wales during this period. Two services did not have suitable NCI or MHMDS denominator data; we therefore calculated suicide rates for 89 mental health services.
Most services had not introduced any key recommendations in 1998 (figure 1). The average number of recommendations implemented increased gradually from 0·3 per service
Discussion
Service providers reported increasing implementation of key service recommendations with time. Implementation of these recommendations was associated with a lower suicide rate in a cross-sectional analysis. In a national before-and-after analysis, reductions in suicide rate were associated with the implementation of a total of seven of the nine recommendations, and these reductions were statistically significant for three recommendations. The provision of 24 h crisis care was associated with
References (35)
- et al.
Community mental-health services and suicide rate in Finland: a nationwide small-area analysis
Lancet
(2009) - et al.
In-patient suicide in a general hospital psychiatric unit: a consequence of inadequate resources?
Gen Hosp Psychiatry
(1993) - et al.
Aftercare and clinical characteristics of people with mental illness who commit suicide: a case-control study
Lancet
(1999) - et al.
Suicide
Lancet
(2009) Mental health. Suicide prevention (SUPRE)
- et al.
Suicide prevention strategies: a systematic review
JAMA
(2005) - et al.
Suicide and a psychiatric diagnosis: a world-wide perspective
World Psychiatry
(2002) Health services and suicide prevention
J Ment Health
(2009)- et al.
Education and debate: prevention of suicide: aspirations and evidence
BMJ
(1994) - et al.
Suicide in psychiatric in-patients in England, 1997 to 2003
Psychol Med
(2006)