Mental Health Reforms in Europe: Further Evaluation of the Dutch Supervision System for Suicides of Mental Health Care Users

For this study, we interviewed clinicians and mental health directors who reported a suicide and inspectors about their views of the usefulness of this procedure. Thirty-four of 38 mental health services participated, for a response rate of 89% (3). Data were gathered through in-depth interviews, conducted from November 2007 to July 2008. Services were 28 large mental health institutions, two addiction services, two general hospital psychiatric wards, and two private practices. Thirty-one clinicians were interviewed: 15 psychiatrists, one physician, nine mental health nurses, and six psychologists. Fifteen inspectors who dealt with suicide notifications were interviewed; four had backgrounds in psychiatry, two in psychology, six in mental health nursing, and three in other fields.

Is supervision of suicides by mental health care recipients useful? One approach is to compare the Dutch system with systems in other countries. To our knowledge, the only published non-Dutch study of this topic is a study in Norway by Rønneberg and Walby (4), who concluded that 19% of suicides by mental health patients were not reported according to requirements and that few institutes seemed to improve the quality of care after suicides. In contrast, there is a long tradition of compliance in the Netherlands, where notification has been required since 1984. Comparing the Dutch system with the National Confidential Inquiry in the United Kingdom is more complex (1), because the aims and methods differ considerably. Advantages of the U.K. system are its anonymous, blame-free nature and the extensive data and knowledge that it has generated.

Our findings highlight medical directors’ and clinicians’ ambivalence about the usefulness of the procedure. The inspectorate’s role can be seen as motivating mental health services to critically self-reflect suicides. Directors and clinicians were unanimously positive in their assessment of the care provided before a suicide. Critically examining such care can lead to improvement in some cases. The fact that the inspectorate supervises this process underlines its importance. Ambivalence about the procedure’s usefulness centered on the issue of guilt implied by the incident-driven work of the inspectorate. A patient’s suicide can have a substantial traumatic impact on a treating clinician (5). Thus the stress evoked by the procedure is an unbeneficial effect. It may be of interest for the inspectorate to determine whether clinicians have been adequately supported by colleagues after a suicide.

In light of the guilt felt by and impact on clinicians, it was perhaps not surprising that none of them felt that the suicide could have been prevented. When clinicians were asked whether, in general, suicide can be prevented, they often answered differently. The general impression of the interviewers was that the absence of consensus on a Dutch standard practice guideline for assessment and treatment of suicidal patients played a significant role in clinicians’ views. The Dutch clinicians had no point of reference with which to compare their treatment policies. Until 2011, they had to rely on foreign guidelines, which do not always align with Dutch service delivery organization. Many reported the use of no-suicide contracts, and many had insufficient knowledge about risk assessment. Also, the pessimistic attitude about improving suicide prevention reported by about a third of the clinicians raises concerns about their willingness to implement policy changes and improvements. Perhaps the 2012 implementation of the new Dutch practice guidelines for assessment and treatment of suicidal behavior will lead to further improvements, especially through better training (6).

In many countries, suicide is regarded as resulting from substandard clinical care. This view is clearly not shared in the Netherlands, which may raise questions about whether Dutch clinicians’ reported inability to prevent some suicides is realistic or whether it reflects attitudes of clinicians toward autonomy or the right of self-determination of severely ill psychiatric patients. Our findings lead us to conclude that Dutch clinicians do their best to provide the highest-quality care in order to prevent suicides. But it is also true that they do not want to prevent suicide at any cost, and they emphasize patients’ autonomy, perhaps more so than in other countries.

The inspectorate’s requirement of a report for every suicide of a mental health care user implies a potential relationship between substandard care and suicide. Research in this area is scarce. Desai and colleagues (7) concluded in an exploratory study that suicide rates are probably not a useful indicator of the quality of care. Research on the relationship between suicide rates and the characteristics of mental health care has yielded conflicting results. Some studies have found a link between lower suicide rates and well-developed community-based mental health services, as opposed to inpatient-oriented services (8). Conversely, some ecological studies have found no association between suicide rates and mental health funding, service provision, or national mental health policies (9). However, a nationwide U.K. study by While and colleagues (10) showed that greater implementation by mental health services of National Confidential Inquiry recommendations was associated with lower suicide rates. Recommendations that were important in this context were provision of 24-hour crisis care, local policies about patients with dual diagnoses, and a multidisciplinary review after a suicide. These findings support the emphasis that the Dutch inspectorate puts on evaluation after a suicide. Also, it would be advisable for the inspectorate to supervise the implementation of suicide prevention measures—both in general, such as provision of adequate 24-hour crisis care, and in terms of specific improvements within a service.

In the Netherlands, the inspectorate changed the notification procedure in May 2011, so that most suicides can be reported in a blame-free manner within the mental health service. Only suicides of patients in involuntary treatment or for which the medical director determines an association with substandard care must be reported to the inspectorate. Services still must evaluate each suicide internally and provide an annual report to the inspectorate of an overview of suicides and resulting policy adjustments. It is hoped that the new procedure will reduce feelings of guilt. However, data about suicides and lessons after evaluations will no longer be collected systematically on a national level, even though such procedures may be viewed as critical for generating recommendations to improve suicide prevention policies. The new procedure will be evaluated.

This study was funded by the Health Care Inspectorate in the Netherlands.

Dr. Robben is an appointed advisor to the Dutch Health Care Inspectorate, which funded the research. The other authors report no competing interests.