Coexisting service-related factors preceding suicide: a network analysis

Area of Science:

• Healthcare quality and patient safety
• Mental health services research
• Suicidology

Background:

• Suicide prevention is a critical public health concern.
• Understanding service-related factors preceding suicide is vital for effective intervention.
• Previous research has not fully elucidated the complex interplay of factors contributing to suicide within healthcare systems.

Purpose of the Study:

• To analyze service-related factors in suicide processes to identify intervention targets.
• To explore the network structure of deficiencies and contributing factors in suicide cases.
• To identify key themes and communities within the data related to suicide prevention failures.

Main Methods:

• Explorative network analysis of post-suicide root cause analysis data.
• Inclusion of 217 suicide cases from Swedish primary and secondary healthcare (2012-2017).
• Analysis of 961 reported incidents, examining topology, centrality indices, and communities.

Main Results:

• Lack of follow-up, evaluations, and documentation were central themes.
• Organizational problems, failing procedures, and miscommunication were significant contributing factors.
• Disrupted treatments, staffing issues, discontinuity, fragile work structures, and inadequate resources emerged as prominent deficiencies.

Conclusions:

• Healthcare providers should prioritize regular follow-ups for at-risk patients.
• Declined or cancelled appointments may signal elevated suicide risk.
• Organizational instability, including work structure, resources, and staffing, presents a potential intervention target requiring further exploration.