Lessons from a comprehensive clinical audit of users of psychiatric services who committed suicide

Objective: Characteristics of patients who committed suicide were examined to provide a picture of the treatment they received before death and to det ermine whether and how the suicides could have been pre vented by the servi ce system. Methods: The unnatural-deaths register was matched to the psychi atric case register in the state of Victoria in Australia to identify suici des by people with a history of public-sector psychiatric service use who c ommitted suicide between July 1, 1989, and June 30, 1994. Data on patient a nd treatment characteristics were examined by three experienced clinicians, who made judgments about whether the suicide could have been prevented had the service system responded differently. Quantitative and qualitative dat a were descriptively analyzed. Results: A total of 629 psychiatric patients who had committed suicide were identified. Seventy-two percent of the pati ents were male, 62 percent were under 40 years old, and 51 percent were unm arried. They had a range of disorders, with the most common being schizophr enia or schizoaffective disorder (36 percent). Sixty-seven percent had prev iously attempted suicide. A total of 311 patients (49 percent) received car e within four weeks of death. Twenty percent of the suicides were considere d preventable. Key factors associated with preventability were poor staff-p atient relationships, incomplete assessments, poor assessment and treatment of depression and psychological problems, and poor continuity of care. Con clusions: Opportunities exist for the psychiatric service system to alter p ractices at several levels and thereby reduce patient suicides.