Should we have an Australian ‘Suicide Toll’?
Death from suicide is too common in Australia. It ranks alongside motor vehicle accidents as a cause of mortality, especially among younger Australians. Despite that, no national or regional ‘suicide tolls’ are published.
Economic circumstances, culture, religion, interpersonal and marital disharmony, shame and guilt are all aetiologic factors in suicide but a significant proportion occur in people suffering from mental illness. I believe accessibility and quality of mental health services must play a role in preventing tragic outcomes, especially for those who made contact with mental health services beforehand.
Mental health professionals who doubt this should reconsider their roles as care providers. We cannot wash our hands of responsibility by saying suicides are “not preventable” and have no relation to the effectiveness of mental health services whether supplied by general practitioners, psychologists, Emergency Departments, inpatient and outpatient public and private psychiatric specialist services, or community-based help lines and information services.
A 2007 Queensland Health (QH) report highlighted problems for psychiatric patients attempting to access a health system under pressure. The report identified 140 unexpected deaths of patients treated by QH during the previous year, 86 of which occurred in mentally ill patients. Most were by suicide within a week of assessment in a QH Emergency Department that did not result in admission, or within a week of discharge after psychiatric admission.
Other studies confirm that a high proportion of suicide deaths followed discharge from hospital. Relentless pressure to limit duration of hospital admission means some patients are discharged too soon, too unwell to return to home. Limited intensive community follow-up of recently discharged patients leads to inadequate monitoring and care.
A peak in suicide deaths following visits to Emergency Departments by mentally ill patients not subsequently admitted to psychiatric beds raises several questions. How good is mental health assessment in Emergency Departments? Are disturbed individuals not being identified accurately? Are threshold admission criteria set too high? Are there insufficient psychiatric inpatient beds available?
The problem is not confined to Australia. In the USA this year, a Congressman was stabbed by his son, who then committed suicide. Prior to that, a hospital bed could not be found for the son despite his admission being mandated by a judge! I wonder how closely was that individual followed up by community mental health services after leaving the Emergency Department.
Cardiovascular disease provides a useful analogy. Diet, family history of heart disease, exercise, stress, high blood pressure, diabetes, and smoking all contribute. However, accessibility and quality of health services available for cardiovascular disease clearly affects cardiovascular morbidity while death rate is an important index of national progress in managing cardiovascular disease. Why should accessibility and quality of mental health services not be regarded as an important index of the effectiveness of mental health services?
What can quality mental health services do?
I propose a Suicide Audit Commission to analyse pathways to death in every case, whatever the circumstances. Careful attention should be paid to the extent and nature of contact with mental health services during the three months before suicide.
Findings of the audit should be reported six-monthly by State, Territory and Health District with relevant commentary about accessibility and quality of services and recommendations about improving these services. This index of the quality of mental health services could be supplemented by publication of an annual State and national ‘Suicide Toll’, an idea whose time has come.