Aftercare and clinical characteristics of people with mental illness who commit suicide: a case-control study

Background Suicide prevention is now a health priority in many countries. I n the UK, there are specific targets for reducing the suicide rate in the g eneral population and in people with mental illness. However, there is almo st no evidence for the effectiveness of health services in reducing suicide , and little evidence linking suicide to any aspect of health-service care. Method We conducted a case-control study of people who committed suicide af ter discharge from psychiatric inpatient care. Cases were a 30-month sample of 149 people who had received an inquest verdict of suicide or open verdi ct in Greater Manchester, and who had a history of psychiatric admission in the 5 years before death. Controls were surviving psychiatric patients ind ividually matched for age, sex, diagnosis, and date of last admission. Case s and controls were compared on aspects of psychiatric care, and on clinica l and social variables, information being obtained from case notes. Findings Those who took their own lives were more likely to have had their care reduced (odds ratio 3.7 [95% CI 1.8-7.6]) at the final appointment in the community before death. Suicide was also associated with a history of s elf harm (3.1[1.7-5.7]), suicidal thoughts during aftercare (1.9 [1.0-3.5]) and the most recent admission as the first illness (2.0 [1.1-3.6]). The as sociations reported above took account of a number of confounding factors, including the predictable risk of suicide judged from case notes. Only 34% of suicides had an identifiable key worker, the essence of the Care Program me Approach. This frequency was no higher than that for controls, reflectin g the difficulty of identifying those likely to commit suicide. Interpretation Reductions in care are strongly associated with suicide by p eople with mental illness, and may be contributory. The implication is that maintaining care beyond the point of clinical recovery is important in pro tecting high-risk individuals. Several clinical variables indicate high ris k but greater risk is not generally addressed in health service provisions.