Population‐based analysis of health care contacts among suicide decedents: identifying opportunities for more targeted suicide prevention strategies

Abstract

The objective of this study was to detail the nature and correlates of mental health and non-mental health care contacts prior to suicide death. We conducted a systematic extraction of data from records at the Office of the Chief Coroner of Ontario of each person who died by suicide in the city of Toronto from 1998 to 2011. Data on 2,835 suicide deaths were linked with provincial health administrative data to identify health care contacts during the 12 months prior to suicide. Sub-populations of suicide decedents based on the presence and type of mental health care contact were described and compared across socio-demographic, clinical and suicide-specific variables. Time periods from last mental health contact to date of death were calculated and a Cox proportional hazards model examined covariates. Among suicide decedents, 91.7% had some type of past-year health care contact prior to death, 66.4% had a mental health care contact, and 25.3% had only non-mental health contacts. The most common type of mental health contact was an outpatient primary care visit (54.0%), followed by an outpatient psychiatric visit (39.8%), an emergency department visit (31.1%), and a psychiatric hospitalization (21.0%). The median time from last mental health contact to death was 18 days (interquartile range 5-63). Mental health contact was significantly associated with female gender, age 25-64, absence of a psychosocial stressor, diagnosis of schizophrenia or bipolar disorder, past suicide attempt, self-poisoning method and absence of a suicide note. Significant differences between sub-populations of suicide decedents based on the presence and nature of their health care contacts suggest the need for targeting of community and clinical-based suicide prevention strategies. The predominance of ambulatory mental health care contacts, often close to the time of death, reinforce the importance of concentrating efforts on embedding risk assessment and care pathways into all routine primary and specialty clinical care, and not only acute care settings.

Anhedonia and suicidal thoughts and behaviors in psychiatric outpatients: The role of acuity

“…Suicide is a leading cause of death in the United States (CDC, 2011), but should be substantially preventable (National Action Alliance for Suicide Prevention, 2014); a majority of people who die by suicide encounter a mental health professional in the months preceding their attempt (Luoma, Martin, & Pearson, 2002;Schaffer et al, 2016). Considerable research has been devoted to identifying factors associated with suicidal thoughts and behaviors (STB; Franklin et al, 2017), such as preexisting mental health conditions (Borges et al, 2010;Nock, Hwang, Sampson, & Kessler, 2010), in an effort to improve risk evaluation.…”

Determinants and Predictive Value of Clinician Assessment of Short‐Term Suicide Risk

“…Suicide and suicide‐related behavior is a prevalent problem in the United States, with over 40,000 suicide deaths, 1 million individuals attempting, and 8 million seriously considering suicide each year (Crosby, Gfroerer, Han, Ortega, & Parks, ). Contact with mental health professionals, such as in an outpatient clinic intake, is a significant point of opportunity for suicide prevention, as approximately one third of suicide decedents encounter mental health services in the year prior to their death (Ilgen et al., ; Luoma, Martin, & Pearson, ; Schaffer et al., ). Accurate clinician assessment of short‐term risk for suicidal thoughts and behaviors (STB) during these initial encounters may directly improve decisions and interventions aimed at preventing suicide.…”

End-of-life care and place of death in adults with serious mental illness: A systematic review and narrative synthesis

“…Characteristics of the 23 included studies are presented in Table 1. Fourteen studies reported health care at end of life (23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36) and 13 studies reported place of death in patients with a serious mental illness (13,28,(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44) and. Four studies reported both outcomes (28,(34)(35)(36).…”

“…There was great variability in the size of the study sample from which the sample of people with serious mental illness. In two studies (28,32), the whole sample comprised eligible adult subjects with serious mental illness, whom were included in the synthesis of results, whilst other studies presented results for subsamples with serious mental illness from a Most studies were from the USA (13,24,(30)(31)(32)34,35,38) and Canada (29,36,43); the remaining studies were from Denmark (41,42), the UK (28,44), France (39), the Netherlands (25), Australia (27,33), New Zealand (23), Japan (40) and Taiwan (26,37). The mean/median age of subjects ranged between 47 and 79.…”

“…Four studies reported outcomes for deaths from natural causes (34,35,38,42), two for unnatural deaths (33,43) and six for a mixed sample of natural and unnatural deaths (24,28,36,40,41,44). One study described the sample's cause of death as "non-sudden", which was an inclusion criteria (25).…”