Elsevier

The Lancet

Volume 379, Issue 9820, 17–23 March 2012, Pages 1005-1012
The Lancet

Articles
Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: a cross-sectional and before-and-after observational study

https://doi.org/10.1016/S0140-6736(11)61712-1Get rights and content

Summary

Background

Research investigating which aspects of mental health service provision are most effective in prevention of suicide is scarce. We aimed to examine the uptake of key mental health service recommendations over time and to investigate the association between their implementation and suicide rates.

Methods

We did a descriptive, cross-sectional, and before-and-after analysis of national suicide data in England and Wales. We collected data for individuals who died by suicide between 1997 and 2006 who were in contact with mental health services in the 12 months before death. Data were obtained as part of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. When denominator data were missing, we used information from the Mental Health Minimum Data Set. We compared suicide rates for services implementing most of the recommendations with those implementing fewer recommendations and examined rates before and after implementation. We stratified results for level of socioeconomic deprivation and size of service provider.

Findings

The average number of recommendations implemented increased from 0·3 per service in 1998 to 7·2 in 2006. Implementation of recommendations was associated with lower suicide rates in both cross-sectional and before-and-after analyses. The provision of 24 h crisis care was associated with the biggest fall in suicide rates: from 11·44 per 10 000 patient contacts per year (95% CI 11·12–11·77) before to 9·32 (8·99–9·67) after (p<0·0001). Local policies on patients with dual diagnosis (10·55; 10·23–10·89 before vs 9·61; 9·18–10·05 after, p=0·0007) and multidisciplinary review after suicide (11·59; 11·31–11·88 before vs 10·48; 10·13–10·84 after, p<0·0001) were also associated with falling rates. Services that did not implement recommendations had little reduction in suicide. The biggest falls in suicide seemed to be in services with the most deprived catchment areas (incidence rate ratio 0·90; 95% CI 0·88–0·92) and the most patients (0·86; 0·84–0·88).

Interpretation

Our findings suggest that aspects of provision of mental health services can affect suicide rates in clinical populations. Investigation of the relation between new initiatives and suicide could help to inform future suicide prevention efforts and improve safety for patients receiving mental health care.

Funding

National Patient Safety Agency, UK.

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

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