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Caroline Cassels

A national study published online February 2 in the Lancet showed that among 91 mental health services in England and Wales that implemented 7 or more of 9 key recommendations, there was a statistically significant decrease in suicide rates, whereas those services that did not adopt the recommendations saw little change.

"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," the researchers, led by Professor Navneet Kapur, MBChB, MMedSc, FRCPsych, MD, Centre for Suicide Prevention, University of Manchester, UK, and colleagues write.

"The rate of suicide in mental health patients is 10 times what it is in the general population, and the main cause of premature death in mental health patients," study coauthor Louis Appleby, MD, told reporters attending a news briefing.

Dr. Appleby added that clinicians and other healthcare workers are sometimes "pessimistic" about the mentally ill and view suicide as "an inevitable consequence" of severe mental illness.

Furthermore, the authors noted that research investigating which aspects of mental health service provision are most effective in suicide prevention is scarce.

"Every clinician who has worked in mental health has had the experience of taking action that protects a suicidal patient, but turning that individual experience into something more systematic into a better service and being able to demonstrate that it's a better service has been proved very difficult in the past," said Dr. Appleby.

However, he added, the establishment of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI) in the United Kingdom in the 1990s — a project that aims to monitor suicide and ultimately improve the quality of mental healthcare in that country —allowed investigators to develop and assess suicide prevention strategies in this high-risk patient population.

Before and After

In the current "before-and-after" cross-sectional study, the investigators examined the uptake of 9 key NCI recommendations from 1998 to 2006 by 91 mental health services and their impact on suicide rates.

These recommendations included the following:

The researchers analyzed data for individuals who died by suicide between 1997 and 2006 and who were in contact with mental health services in the 12 months before their death.

Suicide rates were compared for services that implemented the majority of the recommendations and services that implemented fewer recommendations. The investigators also examined suicide rates before and after implementation.

The investigators found that from 2004 onward, there were fewer suicides in services in which 7 to 9 recommendations had been implemented (10.80 suicides per 10,000 in 2004; 95% confidence interval [CI], 9.99 - 11.65) than in those where 0 to 6 recommendations were implemented (12.63; 95% CI, 11.70 - 13.61).

"We found that Trusts that implemented more of the recommendations had a lower suicide rate — about a 15% reduction," said Dr. Kapur.

He added that the researchers also examined each recommendation to assess its individual impact on reducing suicide rates by comparing rates before and after implementation.

24-Hour Crisis Care

The provision of 24-hour crisis care was associated with the biggest reduction in suicide rates — from 11.4 per 10,000 patient contacts per year before implementation to 9.3 after, or about a 20% reduction in suicide rates. Dr. Appleby explained that such crisis teams provide daily intensive treatment in the patient's home, providing medication in the acute phase of illness as well as talk therapy and social support as the patient recovers.

Local policies on patients with dual diagnoses (10.6 rate before to 9.6 after) and multidisciplinary review after suicide (11•6 before and 10.5 after) were also associated with a reduction in suicide rates. Each of these initiatives was associated with about a 10% reduction in suicide rates, said Dr. Appleby.

According to Dr. Kapur, the researchers estimate that the implementation of the recommendations is associated with 200 to 300 fewer suicides per year.

It is important to note, he added, that mental health services that did not implement these recommendations did not experience a reduction in suicide rates.

The study also revealed that the average number of recommendations implemented increased from 0.3 per service in 1998 to 7.2 in 2006.

The investigators report that the biggest drop in suicide seemed to be in services in the most deprived catchment areas, with a 10% post-intervention reduction.

Mental health services with the most patients also appeared to do better, with a rate 14% lower after intervention than before.

Implications for Other Countries

By 2006, authorities who had implemented between 7 and 9 of these interventions had a suicide rate of 9.1 per 10,000 patient contacts, compared with 11.0 for those who had implemented 0 to 6.

The authors state that their findings suggest that suicide prevention initiatives can reduce suicide rates and that further "investigation of the relationship between new initiatives and suicide could help to inform future suicide prevention efforts and improve safety for patients receiving mental health care."

Further, they note, the findings have "implications for mental health services internationally, particularly those in the USA, Europe, and Australasia, which have also had an increased emphasis on community compared with inpatient treatment."

In an accompanying editorial, Yeates Conwell, MD, and Carole Farley-Toombs, RN, from the University of Rochester Medical Center in Rochester, New York, say the study "lends strong support to the contention that existing recommendations are effective."

However, they note, "we cannot take for granted that even the most seemingly obvious intervention designed to reduce suicide is necessarily effective without evidence, or even that the reduction of suicide is a shared public concern warranting allocation of substantial resources for its prevention. This study is important at each of these levels. To have an even greater effect, we need much more evidence."

The authors and editorialists have disclosed no relevant financial relationships.

Lancet. Published online February 2, 2012.