Suicides of Mental Health Patients in the Community Reflects Increasing Reliance on Crisis Teams

Over 200 suicide deaths per year occur in patients under mental health crisis teams, three times as many as in-patients, according to the University of Manchester's National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, which was published this month. The Annual Report provides the latest figures on suicides, homicides and sudden deaths across the UK from 2014 and highlights the priorities for safer services. This year it also looks back on 20 years of research to identify changing patterns.

The report found that the number of suicides by mental health patients in the UK has risen in recent years, mainly as a result of increases in England. This primarily reflects the large rise in the number of people under mental health care in England. However at the same time the rate of suicide by mental health patients appears to have fallen overall. The Report suggests that this may be explained by a change in the patient population, namely bringing people at lower suicide risk under mental health care.

Suicide numbers amongst inpatients continue to fall, most clearly in England where the decrease has been around 69% from 2000-2014. This is partly explained by cuts to the numbers of inpatient beds: data from the Health and Social Care Information Centre (HSCIC) showed that the number of inpatient beds fell by 40% from 1998 – 2014 and the number of admissions by 20%. However over this time there there has been a fall in the rate as well as the number of inpatient suicides. The fall has been particularly marked since 2003, which was the year the Department of Health introduced a requirement to remove ligature points from wards. Despite this success there were 76 suicides by inpatients in the UK in 2014.

Crisis services providing an alternative to hospital admission are now an established part of mental health care in all UK countries. It is not clear from the Report to what extent the high number of suicides of patients under mental health crisis teams is reflected by the increasing use of these teams, but it is suggested that crisis teams have become the 'default option' in acute care and are used for too many patients at high risk. 44% of patients who commit suicide whilst under the care of crisis teams live alone, indicating that home treatment may not be suitable for people who lack other social supports.

Transition from inpatient care to the community is a time of high risk, particularly the first two weeks after a hospital discharge. A third of patients who die by suicide whilst under the care of crisis team have been under the service for less than one week. A third have been discharged from hospital within the previous two weeks. The Report found that these deaths were linked to admissions lasting less than 7 days, lack of a care plan on discharge and adverse life events. However there has been a fall in post-discharge deaths occurring before first service contact, suggesting recognition of the need for early follow up.

Over key findings of the report include:

• Over half of mental health patients who died by suicide had a history of alcohol or drug misuse. A much smaller group were in contact with specialist substance misuse services.
• Common antecedents of suicide include isolation, economic adversity, alcohol and drug misuse, recent self-harm. Living alone and unemployment have become more frequent antecedents, suggesting greater social adversity.
• Methods of suicide are broadly similar across all UK countries with hanging most common followed by self-poisoning with opiates.
• Over the last 20 years there has been no change in the male to female ratio, but the age profile of patient suicides has changed with a fall in the proportion of patients who are under 35 and a rise in 45-54 and 55-64 year olds. The highest rate of suicide is in men in middle age.

Priorities for Improving Safety

The findings suggest a number of priorities for mental health services in improving safety which should be taken up by mental health providers, commissioners, clinical staff, training organisations, regulations and health service leaders:

• Safer wards: including removal of ligature points; reduced absconding; skilled in-patient observation.
• Care planning and early follow up within 2-3 days of discharge from hospital to community
• No 'out of area' admissions for acutely ill patients
• Although the introduction of 24 hour crisis team appears to add the safety of a service overall, the use of these teams should be kept under regular review and are unlikely to be a safe setting for patients at high risk or who live alone;
• Community outreach teams to support patients who may lose contact with conventional services
• Specialised services for alcohol and drug misuse and 'dual diagnosis' with the ability to manage clinical risk, working closely with mental health services with agreed arrangements for dual diagnosis patients.
• MDT review of patient suicides, with input from family, to learn from adverse events
• Implementing NICE guidance on depression and self-harm
• Personalised risk management without routine checklists
• An awareness of the changing nature of patients at risk of suicide i.e. economic problems, recent immigration and isolation and be able to work with services with specialist expertise in these areas.
• Low turnover of non-medical staff

The Report also highlighted key elements of safer care in the wider health system:

• Liaison psychiatry teams offering 24 hour specialist psychosocial assessment and follow up should be available for self-harming patients, with specific arrangements for people under mental health care.
• Psychosocial assessment of self-harm patients
• Safe prescribing of opiates and anti-depressants i.e. reduced use, short term supplies.
• Diagnosis and treatment of mental health problems especially depression in primary care
• Additional measures for men with mental ill health, including services online and in non-clinical settings

The full report is available here .

For further information on this or any of the points raised in this article, please contact Claire Leonard, Employed Barrister.