Increasing specialist community services like crisis resolution, helping make the transition to adult services smoother for young people, and implementing clinical guidelines are just some of the service changes that are linked to significantly reduced suicide rates in mental health services in England over the last 16 years, according to new research from The University of Manchester.
The study, published in The Lancet Psychiatry journal, by researchers at the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness at The University Manchester also finds that suicide rates were higher in mental health trusts with higher levels of staff turnover, suggesting that organisational factors may be equally important in preventing suicide.
Previous studies examining which aspects of mental health service provision are most effective in preventing suicide are scarce, have been inconsistent in their findings, and limited in scope. This is the first study to look at the impact of specific mental health service improvements in a range of organisational contexts, on suicide rates.
In this study, the authors analysed the impact of 16 recommendations and service changes in all NHS mental health services across England on patient suicide rates between 1997 and 2012. They also looked at whether suicide deaths were related to the way mental health services were organised (using measures such as staff turnover, staff and patient satisfaction, patient complaints).
The research included data from 19,248 individuals who died by suicide in England over the 16-year period and were in contact with mental health services in the 12 months before they died. This represents over a quarter of all suicide deaths in England during this time. The researchers compared suicide rates before and after these recommendations and service changes were introduced.
By 2012, 58 services (94%) had implemented at least 10 of the service changes and 34 (55%) had implemented all 16. The individual service changes that were most widely implemented were removal of noncollapsible ligature points on wards, policies to reduce absconding on in-patient wards, and a mechanism to implement National Institute for Health and Care Excellence (NICE) guidelines.
The five mental health service changes linked to the biggest falls in suicide were: increasing the availability of specialist community services like crisis resolution and home treatment; better management of patients with dual diagnosis (ie, drug or alcohol misuse as well as major mental illness); reviews and information with families after suicide; introducing policies to help manage the transition to adult mental health services for young people; and implementing the NICE guidelines on depression.
The researchers found that implementing recommendations and service changes was associated with significantly lower suicide rates. Each of the 16 recommendations and service changes were linked with 20-30% decrease in the suicide rate (from around 12 suicides per 10,000 contacts with mental health services to approximately 9).
The study also linked suicide rates to some wider organisational factors including higher levels of non-medical (e.g. nursing) staff turnover and reporting of patient safety incidents. However, other factors like staff sickness and patient satisfaction did not appear to affect suicide rates.
Importantly, implementing the five most promising changes had a greater impact in mental health services with low levels of non-medical staff turnover and higher levels of overall reported safety incidents. “A workforce that is constantly changing is likely to affect the continuity of care and this could compromise safety,” explains Professor Nav Kapur, lead author and Head of Suicide Research at the Centre for Suicide Prevention at The University of Manchester.
“High numbers of safety incidents might suggest a culture of openness in which staff and the organisation learn from adverse incidents, but they may also be a warning that there are real patient safety issues.”
The data also show that at least as important as these initiatives might be the organisational context in which they are introduced. These are important findings for mental health services worldwide, particularly in those countries where there is a focus on community care such as the USA, Europe, and Australasia
According to Professor Kapur: “Our study suggests that many of these interventions may prevent suicide and save lives. The data also show that at least as important as these initiatives might be the organisational context in which they are introduced. These are important findings for mental health services worldwide, particularly in those countries where there is a focus on community care such as the USA, Europe, and Australasia.”
Professor Louis Appleby, Director of the National Confidential Inquiry and one of the co-authors of the study added: “This study shows that how clinical staff work can make a difference to patient suicide risk. Mental health trusts with low staff turnover, and where staff reviewed suicide deaths with families had lower suicide rates suggesting that healthy, learning organisations may also be safer.”
Paper, ‘Mental health service changes, organisational factors, and patient suicide in England in 1997–2012: a before-and-after study’, was published in The Lancet Psychiatry Journal.
The Healthcare Quality Improvement Partnership (HQIP) commissions the Mental Health Clinical Outcome Review Programme, NCISH, on behalf of NHS England, NHS Wales, the Scottish Government Health and Social Care Directorate, the Northern Ireland Department of Health, Social Services and Public Safety (DHSSPS), and the States of Jersey and Guernsey.