Systematic Suicide Audit: An Enhanced Method to Assess System Gaps and Mobilize Leaders for Prevention

Abstract

Background and Objectives: In Quebec, Canada, several independent processes are in place to investigate cases of death by suicide. An enhanced multidisciplinary audit process was developed to analyze these cases more thoroughly, with the aim of generating recommendations for suicide prevention. A study was undertaken to evaluate the feasibility and implementability of this process. Methods: The life trajectories of 14 people who died by suicide in Montreal, Canada, in 2016 were reconstructed on the basis of information retrieved by interviewing bereaved relatives and examining coroner investigation files and other records. A multidisciplinary panel that included a representative of families bereaved by suicide then reviewed case summaries to determine unmet needs and service gaps at 3 levels: individual intervention, regional programs, and the provincial health and social services system. Results: The feasibility of the audit process was demonstrated in the context of a public health care system. Thirty-one distinct recommendations were made variably across 13 of the 14 cases reviewed, whereas none had originally been made by the coroner. The recommendations that recurred most often were (1) improve training for professionals and educate the general public regarding depression and substance-related disorders; (2) deploy mobile crisis intervention teams from emergency departments; and (3) provide access to a family physician to all, especially men. Conclusion: Although the audit produced novel recommendations and is implementable, there was resistance from physicians and their hospital mortality review committee against this multidisciplinary audit involving families. These concerns could be alleviated by having the process endorsed by provincial authorities.

Explainable artificial intelligence models for predicting risk of suicide using health administrative data in Quebec

“…A second set of variables are contact with primary care physicians and specialist mental health care, and Emergency Departments (ED) visits, which are indicative of greater need for care, but not always receiving adequate care. Systematic audits have shown that half of suicide cases were in contact in the last year with the ED, 50% in contact with a general practitioner and 25% with a psychiatrist, and deficits have consistently been found in the 3 areas, i.e., coordination of specialist mental health and specialist addiction services at the ED; poor access to referral by general practitioners to specialist mental health or addiction consultation; poor access to mobile crisis resolution teams in support of outpatient services [ 10 ]. The increased risk of suicide among patients presenting for non-intentional trauma at the ED may be due to alcohol abuse.…”

“…In the SHAP summary plot, the top variables, including age, specialist outpatient visits for physical disorders in the past 60 months, regional mental budget, regional dependence budget, psychiatric outpatient psychotherapy in the past 60 months, and quality of local area primary care for depression, provided the insight into the local area programs where the individual lives [ 12 , 72 ]. The association with other specialist physical health visits may seem to be counterintuitive, but it is related to the deficits in identifying suicide risk and consultation with physical mental health or addiction services, as evidenced by at least one case [ 10 ]. Similarly, while capturing the quality of psychiatric outpatient visits with potentially effective and relevant treatments like psychotherapy, the modeling indicated that the low number of psychotherapy visits with a psychiatrist in the past 60 months was associated with lower risk, but not the local area quality of primary care physician practices for depression where the individual was living associated with lower risk.…”

“…referral by general practitioners to specialist mental health or addiction consultation; poor access to mobile crisis resolution teams in support of outpatient services [10]. The increased risk of suicide among patients presenting for non-intentional trauma at the ED may be due to alcohol abuse.…”

“…Mental and substance use disorders are found in 95% of suicide cases, and the population attributable fraction for mental disorder were ranged from 47–74% [ 9 ]. Systematic audits which consist of bottom-up evidence, indicated that deficits in primary care mental health or addiction services can be identified in over 80% of all suicides [ 10 , 11 ]. From a populational perspective, suicide may be related to factors at the individual (e.g., mental disorders), programmatic (e.g., visits to Emergency Departments; adequacy of follow up for depression in the local area primary care), system (e.g., per capita regional budget for substance use disorders), and community level (e.g., neighborhood social deprivation) [ 12 ].…”