Death from suicide is unfortunately a too-common feature of the Australian social fabric. It stands with deaths from road accidents as a major cause of mortality, especially among younger Australians. Yet despite this importance we have no national or regional 'suicide tolls' published regularly as we do for the road toll. In my view this is a major deficit. Others have made similar calls.
Suicide is a multi-determined behavior. Economic circumstances, culture, religion, interpersonal and marital disharmony, shame and guilt all play a part along with other factors. But a significant proportion of suicide deaths occur in settings where the individual is suffering from a mental illness. Surely the accessibility and quality of mental health services has some role to play in preventing these tragic outcomes – especially for those individuals who make contact with mental health services prior to suicide?
If we do not believe this then those of us in the mental health field should reconsider whether we should be in the business of providing care. I do not think we can just wash our hands and say that suicides are 'not preventable' and have no relation to the effectiveness of mental health services at all levels of operation – from the general practitioner and psychologist office, the emergency department, the inpatient and outpatient public and private psychiatric specialist services, to community-based help lines and information services.
The importance of accessibility and quality of mental health services for suicide has been emphasized by recent reports. A 2007 Queensland Health report highlighted the problems for psychiatric patients trying to access a health system under pressure. The report identified 140 unexpected deaths of patients treated by Queensland Health in the previous year.
More than half (86) of these deaths were of mentally ill patients who accessed Queensland Health services. Most of these deaths were by suicide; either within a week of a patient being assessed in a Queensland Health emergency department and not being admitted, or within a week of discharge from a psychiatric admission.
The finding that a high proportion of suicide deaths followed discharge from hospital is consistent with many other studies. Release from hospital treatment carries a serious risk of suicide. But it raises the question of why this occurs and what can quality mental health services do to prevent this? The continuing pressure to limit hospital admission length can lead to patients being discharged too soon – and too unwell to return to home. Limited intensive community follow-up of recently discharged patients is another problem – leading to inadequate monitoring and care of unwell patients.
The finding of another peak in suicide deaths following visits to emergency departments where the mentally ill individual was not admitted to a psychiatric bed raises a further set of concerns. How good are the mental health assessment practices of emergency departments – are disturbed individuals not being identified? Are the threshold criteria for admission to hospital too high – are some unwell individuals denied hospital care when their condition really deserves admission? Are psychiatric inpatient beds not available – leading to the patient being turned away? This is not unique to Australia. A recent case (2013) in the USA of a Congressman being stabbed by his son and then the son committing suicide was linked with the son not being found a hospital bed even after being mandated by a magistrate to be admitted. Finally, how closely was the individual followed up by community mental health services after leaving the emergency department?
These data raise the question of whether the accessibility and quality of mental health services play a role in increasing suicide.
How can we respond to this challenge?
First an analogy. Cardiovascular disease has multiple causes. Diet, family history of heart disease, exercise, stress, high blood pressure, diabetes, and smoking all can contribute. However, no one would seriously propose that the accessibility and quality of health services for cardiovascular disease has no impact on the cardiovascular health of the nation. Furthermore, the death rate from cardiovascular disease is an accepted important index of national progress in reducing the impact of this disease.
I consider it is now time for those of us working in the mental health field to accept that the accessibility and quality of mental health services has a significant impact on suicide and that suicide rates should be seen as one important index of the effectiveness of mental health services.
I propose that an ongoing suicide audit commission be established in each state and territory of Australia. The suicide audit should examine the pathways to death in all cases of suicide, whether occurring in hospital or in the community, or in the public or the private sector. The audit should be required to focus on the pathway to suicide of the individual and the nature of contact over the preceding three months between the individual and mental health services.
The audit should report its findings at six-monthly intervals and by state, territory and intra-state health regions. The audit should make regular comment about the accessibility and quality of services and make recommendations about improving these services.
An ongoing account of suicide statistics and the trends in suicide deaths for each mental health service region should be a public index of an important aspect of the quality of mental health services. An annual state and nation wide 'suicide toll' would be an extension of this proposal. This is an idea whose time has come.
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