Suicidal behaviour : An epidemiological study of suicide and attempted suicide in relation to mental health services

Psychiatric disorders and a history of suicide attempts are the best known risk factors for suicide. Thus, major changes in mental health services and interventions aimed at patients who have attempted suicide might affect the risk of subsequent suicide attempts and suicide. The overall aim of the present thesis was to evaluate the impact of health services on suicidal behaviour, and thereby gain new knowledge relevant for preventing suicidal behaviour. The thesis consists of three papers. Paper I was designed as a prospective cohort study. We investigated whether individuals admitted to inpatient psychiatric care after a suicide attempt had shorter length of stays in the period 1996-2006 than individuals admitted in the former period 1984-1995. We also considered whether length of stays and time period in which the patients received treatment were related to the risk of subsequent suicide attempts and/or suicide. Individuals hospitalised in the period 1996-2006 had significantly shorter stays than individuals hospitalised in the former period (log rank P 0.05). Considering that shortened length of stays might increase the likelihood of incomplete recovery, and thereby increased risk of subsequent suicidal behaviour, our interpretation of the results were that shortened length of stays was compensated by improved mental health services, in particular through the major extension of outpatient services. Paper II was designed as an ecological study. We examined whether increased resources in specialist mental health services in the period 1990-2006 were inversely associated with female and male suicide mortality in five Norwegian health regions. None of the variables that measured mental health service resources (number of man-labour years by all personnel, number of discharges, number of outpatient consultations, number of inpatient days and number of hospital beds) were associated with female or male suicide mortality (adjusted P > 0.05). Paper III was designed as a prospective cohort study. The aim was to explore whether a chain of care intervention aimed at individuals who have attempted suicide was effective in preventing subsequent suicide attempts and suicide. In general, a chain of care intervention means the establishment of an integrated health care system which aims to improve quality of care. We compared the risk of subsequent suicidal behaviour among patients who received a community based chain of care intervention in addition ’to treatment as usual’ with patients who only received ’treatment as usual’. We observed no significant differences between the two groups in the risk of a repeated suicide attempt; not within six months (adjusted OR = 1.08; 95% CI = 0.66-1.74), 12 months (adjusted OR = 0.86; 95% CI = 0.57-1.30) or five years of follow-up (adjusted RR = 0.90; 95 % CI = 0.67-1.22). Nor did we observe significant differences in the risk of committing suicide (adjusted RR = 0.85; 95% CI = 0.46-1.57). Intervention was not assigned to patients for whom the standard aftercare was already deemed sufficient. Thus, we interpreted the results to indicate that this intervention was at least able to render, in terms of outcomes, patients judged to be needier and those judged to be less needy, as indistinguishable