Factors Associated With Suicide in the Month Following Contact With Different Types of Health Services in Quebec

Table 1 summarizes the characteristics of persons who did or did not use any type of health service in the 12 months preceding suicide death between 2000 and 2007 in Quebec. It also summarizes odds ratios for use of outpatient versus all other health services among individuals who used services in the year prior to death. Overall, 82.1% (N=7,265) of individuals had used any type of health service in the past year. Further, 81.6% (N=7,222) had consulted on an outpatient basis, 48.7% (N=4,312) had visited an emergency department, and 28.5% (N=2,519) were hospitalized in the year prior to death.

Among the 2,626 individuals who only consulted on an outpatient basis during the year before suicide death, 36.7% (N=964) died in the month following their last consultation. Among the 2,804 individuals whose most recent health service contact was an emergency room visit, 29.5% (N=828) died in the month following discharge. Among the 1,835 individuals whose most recent health service contact was hospitalization, 75.3% (N=1,381) died in the month following discharge. The factors associated with death in the month following (within 60 days of) an outpatient contact, emergency department visit, and hospital discharge are presented in Table 2.

Close to 18% of persons who died by suicide between 2000 and 2007 had not sought any health services in the year prior to death. In concordance with previous studies (14,15), a majority of these individuals were male; were younger; and lived in peripheral, intermediate, and far or isolated medical regions. In contrast, a majority of persons who died by suicide were in contact with health care services in the year prior to their death, a finding that confirms previous studies (3–6,16). A four-year study using more recent data examined use of health services in the year prior to death in a large sample of individuals in Taiwan who died by suicide. Close to 25% had had contact with a psychiatrist, 80% with physicians other than psychiatrists in hospital settings, and 72% with a general practitioner (5). A Canadian audit of all suicide cases in a given year in New Brunswick indicated that 18% of suicide decedents had seen frontline medical services, 34% had seen specialist services, and 51% had seen any services (including the voluntary sector) in the month prior to death. A total of 49%, 53%, and 77% of the decedents had seen frontline medical services, specialist services, and any services (including the voluntary sector), respectively, in the year prior to death (3). Only 5% of the sample was in contact with addiction services in the past year, even though over 50% had a substance-related disorder (17).

The results of this study showed that the highest risk of suicide death in the month following health service contact was among individuals who were discharged from a hospital (75%). Similar findings reported by others indicate that almost half of suicide deaths occur within four weeks of hospital discharge and before the next follow-up appointment (18,19). This pattern highlights the importance of evaluating a patient’s continued risk of suicide following an emergency department or hospital discharge and of ensuring close follow-up (20).

Gender was not associated with having died by suicide in the month following use of a health service or later, regardless of the setting of the last contact. A previous study of suicides among adolescents, however, showed that the time between suicide and the last contact with health services was shorter among girls than among boys (16). In the study reported here, older age (≥65 years) was associated with increased odds of death by suicide in the month following recent contact with an emergency department. Known risk factors for suicide, including depression, general medical illness, and social isolation, may contribute to an increase in suicide rates among the elderly (21). The presence of general medical disorders may also contribute to underdetection of depression, which can lead to underestimation of the risk of suicide in this population. In fact, although the Quebec national institute of public health reported a decrease in the overall suicide rate in the province between 1999 and 2008, the decrease was due to declines in adolescent suicide rates.

The number of outpatient contacts after a hospital discharge and an emergency department visit was also associated with the occurrence of suicide later than in the month following versus within the month after discharge, which supports studies indicating the importance of follow-up care (9). The results also showed that among individuals who consulted on an outpatient basis only, the odds of dying by suicide within a month of using health services versus dying later was lower for persons who lived in a university medical region rather than in peripheral, intermediate, and far or isolated regions. The university medical region in Quebec consists of three university-affiliated metropolitan areas (Montreal, Quebec, and Eastern townships), which attract more specialist physicians and offer more services compared with other regions (12). The greater scarcity of specialist physicians and psychosocial services in the other regions may have an impact on the quality of follow-up care. In fact, the analyses also showed that the number of outpatient visits in the year prior to death among outpatient users only was associated with suicide death in the month after a health service contact. This may, in part, be indicative of a lack of specialized services or inpatient care in less populated regions.

Suicide death in the month following emergency department and hospital discharge was also associated with an increased number of general medical disorders. This finding concords with research indicating that individuals with general medical disorders may present more complex mental health clinical profiles, which leads to increased suicide risk (22,23). The analyses also showed that the presence of a psychiatric diagnosis was associated with increased odds of suicide in the month following discharge. Pirkola and colleagues (8) reported that affective disorders and schizophrenia were associated with an increased risk of suicide death within one week of discharge.

There was no evidence that the implementation of the Quebec mental health action plan influenced odds of suicide death in the month following contact with emergency department and inpatient services. Studies in other countries have also found that the national policy initiatives had no impact on suicide rates in the early years after their introduction (24,25). Some researchers have shown that results of policy initiatives in public health are more likely to be visible five or more years after the policy’s introduction (26). It should be mentioned that during the study period, suicide rates among adolescents in Quebec decreased. During this period, other population-based suicide prevention strategies were in place, such as a literacy program for adolescents called Partners for Life/Solidaire Pour la Vie and protocols for ensuring liaison between emergency departments and youth centers for adolescents and regional addiction centers (27).

The results of this study should be considered in light of the following limitations. First, analyses were based on data collected in the RAMQ’s health administrative databases. Although these databases are valuable research tools, the data are collected for administrative purposes and do not include some important variables, such as income, level of education, and marital status, that have been associated with the risk of suicide (28). We did, however, control for drug coverage provided by the public insurance plan, which in part controls for employment status. Private insurance plans may also confer access to additional mental health services, such as psychotherapy, that are not covered by public health insurance plans. Second, these administrative databases do not cover contacts with health and social services rendered by community organizations or crisis help lines. Psychological autopsy studies have shown very low use of these services (4), as have epidemiologic surveys on mental health. Third, we were not able to measure and study other population-based suicide prevention strategies in Quebec. Fourth, this study was based on a cohort of individuals who had died by suicide and did not include a control group of persons who had died from other causes. The comparisons were based on use of services by persons who died by suicide in the month following their last contact or more than one month after the last contact. The results showed that later suicide was associated with an increased number of outpatient contacts. However, this finding can be interpreted, in part, as an indicator that persons who died sooner may not have had the same opportunity to attend outpatient consultations compared with persons who died later. Fifth, for emergency department and outpatient contacts that occurred on the same day, it was not possible to ascertain which came first, which may have biased the results.

Notwithstanding these limitations, the major findings of this study indicate that the number of consultations after inpatient and emergency department discharge is significantly associated with later suicide. Consultations may differ according to the profile of need, but the effectiveness of consultation depends upon the quality of primary and specialist mental health care. Audits of health care services among people with mental disorders, such as the survey in New Brunswick (4) and the United Kingdom National Confidential Inquiry on Suicide and Homicide (33), pointed toward key deficits in services provision or coordination. Reduction in suicide rates have been documented when recommendations to fill these service deficits are implemented (29).

To our knowledge, this is the first Canadian study to assess the factors associated with suicide in the month following contact with different types of health services. The data set covered all suicide deaths in the province of Quebec during a seven-year period. As Pirkola and colleagues (8) highlighted, studying the use of services prior to suicide can elucidate patterns of health service use that are associated with longer times to suicide and add time for follow-up care and suicide prevention.

Bickley (10) suggested that programs that deliver community mental health services to individuals who have a severe mental illness and who are at risk of suicide—such as the Care Program in the United Kingdom—can have a positive impact. In Quebec, new clinical guidelines have been proposed to focus on the identification and follow-up of patients in emergency departments who are at high risk of suicide (30,31). The guidelines ensure that a nurse or liaison health professional is present at all times to provide appropriate follow-up with a mental health and addictions specialist during the 48 hours following discharge. For people discharged from a hospital, the guidelines prescribe continued follow-up at home to ensure continuity of care and evaluation of crisis level. Future research should focus on the evaluation of such programs in different health care contexts.

This study was supported in part by a Quebec Health Research Fund (Fonds de Recherche en Santé du Québec ([FRQ-S]) research grant for young investigators held by Dr. Vasiliadis and by FRQ-S research grant 16162. Dr. Vasiliadis is a J2 Research Scholar with the FRQ-S. The authors thank Djamal Berbiche, Ph.D., for work on merging the administrative databases and data set preparation.

Dr. Lesage reports receiving research grant and advisory panel payments from “Prends Soin de Toi” improvements in primary mental health care financed by AstraZeneca. The other authors report no competing interests.