Suicide and community psychiatric care a preliminary report Cantor CH, Burnett PC, Quinn J, Nizette D, Brook C. Suicide and community psychiatric care - a preliminary report. Acta Psychiatr Scand 1992: 85: 229-233.
1
A preliminary survey of 34 suicides among patients attending community services for the chronically mentally ill revealed a rate of 520 per 100,000 admitted. In contrast to earlier hospital surveys, no risk variables were identified for patients dying by suicide. Thirty-four percent of suicides occurred within one week of the last treatment and 59% within 3 months of service entry. It appears that early and intensive follow-up may be necessary to prevent suicide among patients receiving community psychiatric care.
Much has been written about the incidence and characteristics of suicide in a variety of hospital settings, including inpatient, daypatient and outpatient services (1). Of 14 such studies published since 1980 (1-14), 11 reported suicide rates ranging from 50 to 61 1 per 100,000 admissions, with a mean of 274 per 100,000. Variation in the rates reported depended on the type of hospital, whether outpatients were included and on other methodological issues. If suicides occur in the relatively closed environment of a psychiatric hospital, might the less supportive although more libertarian environment associated with community care heighten the risk of suicide? It has already been suggested that suicide, particularly by young male schizophrenics, may be a consequence of deinstitutionalization (15). At times deinstitutionalization has outstripped the provision of community care (16). Hoffman & Modestin (12) have called for research into aftercare of the chronically mentally ill who are suicidal. Although some of the previous studies cited above have included patients discharged from hospitals, none were conducted from a community-based psychiatric perspective. The aims of the current study were to assess whether community psychiatric care may be associated with different levels of suicide mortality and to identify predictor variables for suicide in such settings.
-
C. H. Cantor’, P. C. Burnett’, J. Quinn3, D. Nizette4, C. Brook5
’
Mental Health Branch, Queensland Department of Health, Department of Psychology, Queensland University of Technology, Senior Community Psychiatric Nurse, Valley Community Psychiatry Service, Brisbane, Baillie Henderson Psychiatric Hospital, Toowoomba, Queensland University of Technology, Brisbane, Australia
Key words: community care: suicide C.H. Cantor, Mental Health Branch, Queensland Department of Health, 147-163 Charlotte Street, GPO Box 48, Brisbane 4001, Australia Accepted for publication November 2, 199 1
Materials and methods
The names and accompanying data of all people who committed suicide in Brisbane, Australia (population: 1.215 million in 1987) from January 1, 1986 to June 30, 1989 (42 months) were obtained from the Laboratory of Pathology and Microbiology (LPM), which monitors all coroner’s death reports. Subject identification data were then linked with the registers of the 4 Brisbane Community Psychiatry Services (BCPS) and common cases were identified. These services provide care to a population with poor prognosis conditions, such as chronic psychoses, who tended to be noncompliant and disorganized with regards to their longitudinal care. Elements of the services included care based from community mental health centres in the centre of relevant localities. Although traditional outpatient clinics were provided, a significant emphasis was on home visiting, especially in crises and for those refusing to attend the centre. Attempts were made to minimize patients dropping out of care. Services were restricted to the hours of 0830-1700. There was a strong multidisciplinary orientation and an array of rehabilitation services were provided. No fees were charged for any consultations. State hospitals and private practitioners provide other standard forms of care. Approximately one third of referrals are self-initiated, one third from hospitals for aftercare and 15-20% from other medical practitioners. 229
Cantor et al. Chart searches were conducted on the linked cases to obtain sociodemographic and clinical data. For comparison, a contrast group (n = 34) was formed by matching the sex and age (within 5 years) of the suicides with other patients receiving treatment from BCPS (7). The proportion of contrasts selected from each of the 4 services was the same as the suicides. The sociodemographic variables surveyed were sex, age, domestic situation, employment status, history of parental separation and presence of children. The clinical variables were depression in the last 3 months, recent or past history of alcohol or drug abuse or dependence, physical illness, mental illness in first-degree relatives, past history of suicide attempts, assessment of suicide risk, previous hospitalizations, psychiatric diagnosis and history of violence. The treatment variables were whether the care given included home visits, case management, specific programmes and crisis contact. Medication was not included, as most patients were on medication and to reach valid conclusions the analysis would have been excessively complex. Variables pertaining specifically to the suicide group were interval between last hospitalization and suicide, whether the suicide was noted in file, interval between last treatment and suicide, length of time in treatment with BCPS and method of suicide. Inpatient suicides were included, as care of the chronically ill in the community frequently requires episodes of hospitalization. When subjects had a number of treatment episodes with a particular service, they were counted as being admitted only once to an individual service. The ratings for all variables depict the presence or absence of the variable. The rating process relied on documentation and did not assess the adequacy of the assessments or services. When the presence or absence of a variable was not recorded, the analysis was conducted on the reduced sample size. Chisquare with Yates’ correction was used to assess for differences in the frequencies of each group’s responses for each of the variables. To determine caregivers’ awareness of suicides, all staff individually were asked to supply the names of the patients they knew had committed suicide. Results
A total of 542 people committed suicide in Brisbane in the 41-month study period (annual rate 12.9 per 100,000). Thirty-four of these had received treatment over different intervals in one or more of the 4 BCPS. Given that BCPS treated 6550 people during the study period, 0.52% of the patients died by suicide. Twenty-four (7 1%) of the BCPS suicides were male and 10 (29%) were female, giving a M:F ratio of 3.3:l. The age range for BCPS suicides was 19-51 years (mean 38) whereas for contrasts the age
230
range was 22-48 (mean 39). Table 1 outlines the demographic characteristics of the suicide and contrast groups. No significant differences were found between the groups. Data pertaining to the clinical variables are described in Table 2. None of the variables assessed discriminated between suicides and contrasts. Four treatment variables (home visits, case management, specific programmes and crisis contacts) also failed to discriminate the 2 groups. The frequencies for the variables that relate specifically to the suicides are presented in Table 3. The predominant methods of suicides were shooting (23 %), self-poisoning (23 %), and jumping (23 %). The Australian Bureau of Statistics (17) figures for the Brisbane population were shooting (28 %), selfpoisoning (24%), and jumping (6.5%). The overrepresentation of severely mentally ill persons in suicides by jumping has been discussed previously (18). Discussion
Thirty-four of 6550 patients of the BCPS died of suicide during the 42 months. This figure represents a frequency of 520 per 100,000 admitted (individuals being counted once regardless of how many treatment episodes they received). This definition of frequency only allows approximate comparisons with hospital admission frequencies or rates per first year of discharge in studies of patients discharged from hospitals. Nevertheless, our frequency appears higher than the mean hospital frequency of 274 per 100,000 admissions obtained from a review of the 11 studies cited in the introduction. However, our frequency Table 1. Demographic characteristics
Living arrangements Alone With family Boarding No fixed address
Suicides (n=34)
Contrasts (n=34)
10 13 6 2
6 16 11 0
3 9
Employment status Employed Unemployed Pension Other
17 1
10 8 15 1
Have children Yes No
11 16
12 21
Parents separated before 17 years Yes No
7 10
7 19
No significant differences existed between the groups. Where n< 34 the shortfall is accounted for by the absence of recorded data.
Suicide and community care Table 2. Clinical variables
Table 3. Descriptors of the suicides Suicides (n=34)
Psychiatric diagnosis Schizophrenia or psychosis Affective disorder Adjustment disorder Personality disorder Other
14 11 6 2 1
13 6 6 5 4
Depression in the last 3 months Yes No
20 11
ia
Physical illness Yes No
12 15
13 16
12 14
6 13
9 21
2 16
9
History of alcohol abuse or dependence Yes No History of drug abuse or dependence Yes No History of violence Yes No
8 20
12 15
Previous hospitalizations Yes No
24 6
20 14
Past history of suicide attempts Yes No
a 12
6 16
Completed suicide in first-degree relatives Yes No
3 10
1 11
8 9
5 17
4
4
4
9
15 19
15 19
Mental illness in first-degree relatives Yes No Alcohol or drug abuse in first-degree relatives Yes No Suicide risk noted Yes No
n
Contrasts (n=34)
None of the differences reached statistical significance
seems in keeping with 2 recent studies of patients discharged from hospitals. Black et al. in Iowa, USA (1 1) found a frequency of 6 11 per 100,000 discharges in the year following discharge. Hoffman & Modestin in Berne, Switzerland (1987) (12) similarly found a frequency of 473 per 100,000 discharges in the year following discharge. These 2 studies plus our own suggest that aftercare may be associated with higher frequencies of suicide than institutional care. A total of 508 (94;;) of the suicides were by people not attending the services. The detection rate was low because the early part of the study period coincided with the establishment of the community ser-
Length of time in BCPS treatment Less than 1 week 1 week to a month 1 to 3 months 3 to 6 months Greater than 6 months Interval between last hospitalization and suicide In hospital Less than 1 week 1 week to 1 month 1 to 3 months 3 to 6 months Greater than 6 months No hospitalizations Interval between last treatment and suicide < 1 week 1 week to 1 month 1-3 months 3-6 months > 6 months Method of suicide Shooting Poisoning Jumping Hanging or suffocation Gassing Drowning Other Suicide noted in file or known about Yes No
4 4 12 4 10
2 3 3 2 2
a 6
11 6 3 5 7
8
8
a 3 3 1 3 21 13
Where n
1
A preliminary survey of 34 suicides among patients attending community services for the chronically mentally ill revealed a rate of 520 per 100,000 admitted. In contrast to earlier hospital surveys, no risk variables were identified for patients dying by suicide. Thirty-four percent of suicides occurred within one week of the last treatment and 59% within 3 months of service entry. It appears that early and intensive follow-up may be necessary to prevent suicide among patients receiving community psychiatric care.
Much has been written about the incidence and characteristics of suicide in a variety of hospital settings, including inpatient, daypatient and outpatient services (1). Of 14 such studies published since 1980 (1-14), 11 reported suicide rates ranging from 50 to 61 1 per 100,000 admissions, with a mean of 274 per 100,000. Variation in the rates reported depended on the type of hospital, whether outpatients were included and on other methodological issues. If suicides occur in the relatively closed environment of a psychiatric hospital, might the less supportive although more libertarian environment associated with community care heighten the risk of suicide? It has already been suggested that suicide, particularly by young male schizophrenics, may be a consequence of deinstitutionalization (15). At times deinstitutionalization has outstripped the provision of community care (16). Hoffman & Modestin (12) have called for research into aftercare of the chronically mentally ill who are suicidal. Although some of the previous studies cited above have included patients discharged from hospitals, none were conducted from a community-based psychiatric perspective. The aims of the current study were to assess whether community psychiatric care may be associated with different levels of suicide mortality and to identify predictor variables for suicide in such settings.
-
C. H. Cantor’, P. C. Burnett’, J. Quinn3, D. Nizette4, C. Brook5
’
Mental Health Branch, Queensland Department of Health, Department of Psychology, Queensland University of Technology, Senior Community Psychiatric Nurse, Valley Community Psychiatry Service, Brisbane, Baillie Henderson Psychiatric Hospital, Toowoomba, Queensland University of Technology, Brisbane, Australia
Key words: community care: suicide C.H. Cantor, Mental Health Branch, Queensland Department of Health, 147-163 Charlotte Street, GPO Box 48, Brisbane 4001, Australia Accepted for publication November 2, 199 1
Materials and methods
The names and accompanying data of all people who committed suicide in Brisbane, Australia (population: 1.215 million in 1987) from January 1, 1986 to June 30, 1989 (42 months) were obtained from the Laboratory of Pathology and Microbiology (LPM), which monitors all coroner’s death reports. Subject identification data were then linked with the registers of the 4 Brisbane Community Psychiatry Services (BCPS) and common cases were identified. These services provide care to a population with poor prognosis conditions, such as chronic psychoses, who tended to be noncompliant and disorganized with regards to their longitudinal care. Elements of the services included care based from community mental health centres in the centre of relevant localities. Although traditional outpatient clinics were provided, a significant emphasis was on home visiting, especially in crises and for those refusing to attend the centre. Attempts were made to minimize patients dropping out of care. Services were restricted to the hours of 0830-1700. There was a strong multidisciplinary orientation and an array of rehabilitation services were provided. No fees were charged for any consultations. State hospitals and private practitioners provide other standard forms of care. Approximately one third of referrals are self-initiated, one third from hospitals for aftercare and 15-20% from other medical practitioners. 229
Cantor et al. Chart searches were conducted on the linked cases to obtain sociodemographic and clinical data. For comparison, a contrast group (n = 34) was formed by matching the sex and age (within 5 years) of the suicides with other patients receiving treatment from BCPS (7). The proportion of contrasts selected from each of the 4 services was the same as the suicides. The sociodemographic variables surveyed were sex, age, domestic situation, employment status, history of parental separation and presence of children. The clinical variables were depression in the last 3 months, recent or past history of alcohol or drug abuse or dependence, physical illness, mental illness in first-degree relatives, past history of suicide attempts, assessment of suicide risk, previous hospitalizations, psychiatric diagnosis and history of violence. The treatment variables were whether the care given included home visits, case management, specific programmes and crisis contact. Medication was not included, as most patients were on medication and to reach valid conclusions the analysis would have been excessively complex. Variables pertaining specifically to the suicide group were interval between last hospitalization and suicide, whether the suicide was noted in file, interval between last treatment and suicide, length of time in treatment with BCPS and method of suicide. Inpatient suicides were included, as care of the chronically ill in the community frequently requires episodes of hospitalization. When subjects had a number of treatment episodes with a particular service, they were counted as being admitted only once to an individual service. The ratings for all variables depict the presence or absence of the variable. The rating process relied on documentation and did not assess the adequacy of the assessments or services. When the presence or absence of a variable was not recorded, the analysis was conducted on the reduced sample size. Chisquare with Yates’ correction was used to assess for differences in the frequencies of each group’s responses for each of the variables. To determine caregivers’ awareness of suicides, all staff individually were asked to supply the names of the patients they knew had committed suicide. Results
A total of 542 people committed suicide in Brisbane in the 41-month study period (annual rate 12.9 per 100,000). Thirty-four of these had received treatment over different intervals in one or more of the 4 BCPS. Given that BCPS treated 6550 people during the study period, 0.52% of the patients died by suicide. Twenty-four (7 1%) of the BCPS suicides were male and 10 (29%) were female, giving a M:F ratio of 3.3:l. The age range for BCPS suicides was 19-51 years (mean 38) whereas for contrasts the age
230
range was 22-48 (mean 39). Table 1 outlines the demographic characteristics of the suicide and contrast groups. No significant differences were found between the groups. Data pertaining to the clinical variables are described in Table 2. None of the variables assessed discriminated between suicides and contrasts. Four treatment variables (home visits, case management, specific programmes and crisis contacts) also failed to discriminate the 2 groups. The frequencies for the variables that relate specifically to the suicides are presented in Table 3. The predominant methods of suicides were shooting (23 %), self-poisoning (23 %), and jumping (23 %). The Australian Bureau of Statistics (17) figures for the Brisbane population were shooting (28 %), selfpoisoning (24%), and jumping (6.5%). The overrepresentation of severely mentally ill persons in suicides by jumping has been discussed previously (18). Discussion
Thirty-four of 6550 patients of the BCPS died of suicide during the 42 months. This figure represents a frequency of 520 per 100,000 admitted (individuals being counted once regardless of how many treatment episodes they received). This definition of frequency only allows approximate comparisons with hospital admission frequencies or rates per first year of discharge in studies of patients discharged from hospitals. Nevertheless, our frequency appears higher than the mean hospital frequency of 274 per 100,000 admissions obtained from a review of the 11 studies cited in the introduction. However, our frequency Table 1. Demographic characteristics
Living arrangements Alone With family Boarding No fixed address
Suicides (n=34)
Contrasts (n=34)
10 13 6 2
6 16 11 0
3 9
Employment status Employed Unemployed Pension Other
17 1
10 8 15 1
Have children Yes No
11 16
12 21
Parents separated before 17 years Yes No
7 10
7 19
No significant differences existed between the groups. Where n< 34 the shortfall is accounted for by the absence of recorded data.
Suicide and community care Table 2. Clinical variables
Table 3. Descriptors of the suicides Suicides (n=34)
Psychiatric diagnosis Schizophrenia or psychosis Affective disorder Adjustment disorder Personality disorder Other
14 11 6 2 1
13 6 6 5 4
Depression in the last 3 months Yes No
20 11
ia
Physical illness Yes No
12 15
13 16
12 14
6 13
9 21
2 16
9
History of alcohol abuse or dependence Yes No History of drug abuse or dependence Yes No History of violence Yes No
8 20
12 15
Previous hospitalizations Yes No
24 6
20 14
Past history of suicide attempts Yes No
a 12
6 16
Completed suicide in first-degree relatives Yes No
3 10
1 11
8 9
5 17
4
4
4
9
15 19
15 19
Mental illness in first-degree relatives Yes No Alcohol or drug abuse in first-degree relatives Yes No Suicide risk noted Yes No
n
Contrasts (n=34)
None of the differences reached statistical significance
seems in keeping with 2 recent studies of patients discharged from hospitals. Black et al. in Iowa, USA (1 1) found a frequency of 6 11 per 100,000 discharges in the year following discharge. Hoffman & Modestin in Berne, Switzerland (1987) (12) similarly found a frequency of 473 per 100,000 discharges in the year following discharge. These 2 studies plus our own suggest that aftercare may be associated with higher frequencies of suicide than institutional care. A total of 508 (94;;) of the suicides were by people not attending the services. The detection rate was low because the early part of the study period coincided with the establishment of the community ser-
Length of time in BCPS treatment Less than 1 week 1 week to a month 1 to 3 months 3 to 6 months Greater than 6 months Interval between last hospitalization and suicide In hospital Less than 1 week 1 week to 1 month 1 to 3 months 3 to 6 months Greater than 6 months No hospitalizations Interval between last treatment and suicide < 1 week 1 week to 1 month 1-3 months 3-6 months > 6 months Method of suicide Shooting Poisoning Jumping Hanging or suffocation Gassing Drowning Other Suicide noted in file or known about Yes No
4 4 12 4 10
2 3 3 2 2
a 6
11 6 3 5 7
8
8
a 3 3 1 3 21 13
Where n
