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

Suicide prevention is now a health priority in many countries. In the UK, there are specific targets for reducing the suicide rate in the general population and in people with mental illness. However, there is almost no evidence for the effectiveness of health services in reducing suicide, and little evidence linking suicide to any aspect of health-service care.

We conducted a case-control study of people who committed suicide after discharge from psychiatric inpatient care. Cases were a 30-month sample of 149 people who had received an inquest verdict of suicide or open verdict in Greater Manchester, and who had a history of psychiatric admission in the 5 years before death. Controls were surviving psychiatric patients individually matched for age, sex, diagnosis, and date of last admission. Cases and controls were compared on aspects of psychiatric care, and on clinical and social variables, information being obtained from case notes.

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 self-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 associations 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 Programme Approach. This frequency was no higher than that for controls, reflecting the difficulty of identifying those likely to commit suicide.

Reductions in care are strongly associated with suicide by people with mental illness, and may be contributory. The implication is that maintaining care beyond the point of clinical recovery is important in protecting high-risk individuals. Several clinical variables indicate high risk but greater risk is not generally addressed in health service provisions.