Increasing specialist community services like crisis resolution, helping make the transition to adult services smoother for young people, and implementing clinical guidelines are just some of the service changes that are linked to significantly reduced suicide rates in mental health services in England over the last 16 years, according to new research published in The Lancet Psychiatry journal.
The study by researchers at the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness at the University Manchester also finds that suicide rates were higher in mental health trusts with higher levels of staff turnover, suggesting that organisational factors may be equally important in preventing suicide.
Previous studies examining which aspects of mental health service provision are most effective in preventing suicide are scarce, have been inconsistent in their findings, and limited in scope. This is the first study to look at the impact of specific mental health service improvements in a range of organisational contexts, on suicide rates.
In this study, the authors analysed the impact of 16 recommendations and service changes  in all National Health Service (NHS) mental health services across England on patient suicide rates between 1997 and 2012. They also looked at whether suicide deaths were related to the way mental health services were organised (using measures such as staff turnover, staff and patient satisfaction, patient complaints). The research included data from 19248 individuals who died by suicide in England over the 16-year period and were in contact with mental health services in the 12 months before they died. This represents over a quarter of all suicide deaths in England during this time. The researchers compared suicide rates before and after these recommendations and service changes were introduced.
By 2012, 58 services (94%) had implemented at least 10 of the service changes and 34 (55%) had implemented all 16. The individual service changes that were most widely implemented were removal of non¬collapsible ligature points on wards, policies to reduce absconding on in-patient wards, and a mechanism to implement National Institute for Health and Care Excellence (NICE) guidelines.
The five mental health service changes linked to the biggest falls in suicide were: increasing the availability of specialist community services like crisis resolution and home treatment; better management of patients with dual diagnosis (ie, drug or alcohol misuse as well as major mental illness); reviews and information with families after suicide; introducing policies to help manage the transition to adult mental health services for young people; and implementing the NICE guidelines on depression (figure 1).
The researchers found that implementing recommendations and service changes was associated with significantly lower suicide rates. Each of the 16 recommendations and service changes were linked with 20-30% decrease in the suicide rate (from around 12 suicides per 10000 contacts with mental health services to approximately 9; table 1).
The study also linked suicide rates to some wider organisational factors including higher levels of non-medical (e.g. nursing) staff turnover and reporting of patient safety incidents. However, other factors like staff sickness and patient satisfaction did not appear to affect suicide rates (table 2).
Importantly, implementing the five most promising changes had a greater impact in mental health services with low levels of non-medical staff turnover and higher levels of overall reported safety incidents (table 3). "A workforce that is constantly changing is likely to affect the continuity of care and this could compromise safety," explains Professor Nav Kapur, lead author and Head of Suicide Research at the Centre for Suicide Prevention at the University of Manchester in the UK. "High numbers of safety incidents might suggest a culture of openness in which staff and the organisation learn from adverse incidents, but they may also be a warning that there are real patient safety issues."
According to Professor Kapur, "Our study suggests that many of these interventions may prevent suicide and save lives. The data also show that at least as important as these initiatives might be the organisational context in which they are introduced. These are important findings for mental health services worldwide, particularly in those countries where there is a focus on community care such as the USA, Europe, and Australasia."
Professor Louis Appleby, Director of the National Confidential Inquiry and one of the co-authors of the study added: "This study shows that how clinical staff work can make a difference to patient suicide risk. Mental health trusts with low staff turnover, and where staff reviewed suicide deaths with families had lower suicide rates suggesting that healthy, learning organisations may also be safer."
Writing in a linked Comment, Dr Matthew Spittal and Dr Marie Bismark from The University of Melbourne in Australia say, "Although the research took place in England, health services worldwide are looking for better ways to identify, assess, and safely care for people at risk of suicidal behaviour. Following the tragedies of many preventable deaths, numerous inquiries have recommended that more attention should be paid to implementing guidelines, sharing information with families, training staff, providing crisis and community care, and addressing substance misuse. Kapur and colleagues give added weight and urgency to these recommendations and remind us of the benefits of lifting our gaze from treating individual patients to addressing the broader determinants of care."
NOTES TO EDITORS:
This study was funded by the Healthcare Quality Improvement Partnership.
When covering a suicide-related issue, please consider following Samaritans' media guidelines on the reporting of suicide, due to the potentially damaging consequences of irresponsible reporting: http://www.
 The researchers surveyed the medical directors of all mental health services in the NHS to establish the extent to which implementation of suicide prevention recommendations and service changes reduced suicide rates. The survey examined 16 key recommendations for safer services from the National Confidential Inquiry into Suicide and Homicide by people with Mental Illness (NCISH) including: ward safety (eg, removing ligature points), availability of community services (eg, an assertive outreach team to provide community support to patients), staff training (eg, in suicide risk management), adoption of specific policies (eg, policy regarding response to inpatients who abscond), and adoption of NICE guidelines (eg, on depression and self-harm).
 They used data from annual reports, national databases, and staff and patient surveys to measure staffing characteristics (eg, staff turnover and sickness), patient satisfaction (eg, complaints), and service configuration (eg, safety incidents, length hospital stay).
 Quotes direct from authors and cannot be found in text of Article.
 Professor Kapur is Professor of Psychiatry and Population Health at the University of Manchester and an Honorary Consultant Psychiatrist at Manchester Mental Health and Social Care Trust
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