Treatment of Mental Illness Prior to Suicide: A National Investigation of 12,909 patients, 2001–2016

Between 2001 and 2016, a total of 77,698 suicides occurred in the general population in England and Wales, of whom 20,346 (26.2%) were patients (i.e., had been in contact with mental health services in the 12 months prior to death). Of the patients, 19,967 (98.1%) received a primary psychiatric diagnosis at the time of death. Two-thirds (N=12,909, 64.7%) had one of the main diagnoses that were the focus of this study: depression (N=6,832, 52.9%), schizophrenia (N=3,409, 26.4%), bipolar affective disorder (N=1,807, 13.9%), or an anxiety disorder (N=861, 6.7%). These patients were included for analysis. The remaining 35% (N=7,058) of patients who were excluded received other diagnoses, including unspecified personality disorder, alcohol or drug dependence/misuse, dementia, and adjustment disorders.

Two-thirds of the sample were male (N=8,346, 64.7%) and the median age was 48 years (range 10–96). A majority were unmarried or not cohabiting (N=8,520, 67.3%), lived alone (N=5,593, 43.3%), or were unemployed (N=4,838, 37.5%). A total of 904 (7.3%) patients had a history of imprisonment. Previous self-harm (N=8,184, 64.8%), alcohol misuse (N=4,578, 36.4%), and drug misuse (N=3,379, 26.9%) were common features of patients who died by suicide.

Our results suggest that in a clinical sample of patients who died by suicide and had been in recent contact with mental health services, not all were receiving appropriate pharmacological or psychological treatment at the time of death. Levels of nontreatment ranged from around 20% among patients with depression or bipolar affective disorder to around 30% among those with schizophrenia or anxiety disorders. The reasons for not receiving treatment were a combination of either not being prescribed treatment or not adhering to it, and the relative contribution of these factors varied by diagnosis. Levels of nonprescription were highest for patients with anxiety and depressive disorders, while levels of nonadherence were highest for patients with schizophrenia and bipolar disorder. We found that certain patient characteristics were associated with undertreatment, including demographic (gender, age), social (living alone, unemployment), behavioral (substance misuse), and clinical (comorbid personality disorder, medication side effects) factors.

Although our study reported on a national case series of patient suicide deaths, the findings should be considered in the context of several methodological limitations. The case-series methodology prevents examination of causal relationships between clinical factors and treatment receipt. Clinical information was collected retrospectively on the basis of the account of the clinician involved, with diagnoses based on ICD-10 criteria and not standardized interviews. However, clinicians used both case notes and personal knowledge of the patient to provide information, and the validity of NCISH questionnaire data has been established (19). Missing treatment data were interpreted to mean the patient had not received treatment. However, the health care team likely would have knowledge of relevant prescribed treatment. We restricted our analysis to NICE-recommended treatment so we could investigate treatment received by patients with the most common psychiatric diagnoses in comparison with national guidelines. We therefore did not include other treatments recommended in national and international guidelines, such as those from the British Association for Psychopharmacology or the American Psychiatric Association. We were unable to examine treatment specifically received for comorbid substance use disorders, although this treatment would apply to only a minority of patients in our sample. A lack of available information prevented a detailed examination of nonpharmacological treatments and adherence prior to suicide, and we could not break down treatment by modality or number of treatment sessions.

Our focus in this study was on a clinical sample, in particular patients in recent contact with mental health services before death. Our diagnostic inclusion criteria meant that 65% of this sample were included in the study. Our definition of recent contact as contact within the 12 months prior to death meant we could not generalize findings to all psychiatric patients; this time frame was selected because of proximity of care and the potential for services to intervene and prevent suicide. Our sample represented 17% of all general population suicide deaths during the study period. We did not examine treatment receipt among people who had died by suicide and who were not in contact with secondary mental health services, many of whom likely had been treated solely by their general practitioner. This population warrants further study.

One of the assumptions underlying the study rationale was that pharmacological and psychological treatment helps to prevent suicidal behavior, and the more people who are being actively treated the better. The latter assertion in particular might be regarded as contentious, given international concerns about overprescription and the medicalization of normal human emotion (20, 21). Moreover, this study was not designed to explore the potential positive effects of patient autonomy in treatment selection; for some patients, nonadherence may be an active choice taken after careful consideration.

We found that nonadherence levels were higher among patients with more severe mental disorders. Factors known to affect nonadherence in clinical populations include characteristics of the medication itself (e.g., extrapyramidal symptoms or weight gain) (22) and sedation (23). We found that medication side effects were associated with nonreceipt of treatment, although these were less common in our sample than some of the other factors examined. Nonadherence may also be a direct consequence of the illness itself, for example during manic episodes among patients with bipolar disorder (24), as well as a result of personal choice by the patient (25). Although self-harm might be expected to influence nonreceipt of treatment (e.g., fewer people with a history of self-harm being prescribed psychotropic medication), our findings did not show this association. This finding could reflect the clinical severity of the overall sample, which comprised only patients recently treated in specialist mental health services.

Our finding that certain patient characteristics influenced the receipt of treatment support a recent Adult Psychiatric Morbidity Survey (26), which found fewer men than women and younger than older people receiving medication and psychological therapy. This finding may reflect lower levels of service contact in these groups. Inequalities in access to treatment for BAME groups, including lower rates of prescribed antidepressants in primary care (27) and fewer individuals receiving psychological therapies (28), have also been previously demonstrated. We found that a history of alcohol and drug misuse was an important predictor of nonreceipt of treatment. The impact of comorbid substance misuse on adherence has been studied extensively, and conclusions are consistent with prior research in showing an association with poorer treatment outcomes (29).

Our findings suggest that mental illness may be undertreated among patients who have been in recent contact with specialist mental health services prior to suicide. Undertreatment is likely to be even higher among people who have not been in contact with specialist care (26). Previous research has shown that variables such as living alone (30), male gender, and a history of alcohol and drug misuse (31) can be associated with undertreatment. Part of the impact of these factors may be a lack of access to services (e.g., young men being reluctant to seek psychiatric help) (32). However, our findings indicate that even when certain groups are in contact with services, they may still be less likely to receive treatment, supporting a recent review of the challenges in health equity for marginalized individuals (33).

Clinicians should be aware that undertreatment can result from a lack of recommended prescribing as well as nonadherence and that the relative importance of these factors varies by psychiatric diagnosis. For patients with schizophrenia and bipolar affective disorder, improving adherence may be more important, whereas for patients with anxiety disorders and depression, strategies to improve recognition of symptoms and treatment may be helpful. Interventions to improve adherence include enhancing the therapeutic alliance (34) and promoting positive attitudes toward medication (35). Of course, appropriate and targeted prescribing of treatment can also play a role in enhancing adherence (36), as can improving patient engagement and supporting informed choice (37). Motivational interventions, such as electronic reminder systems and motivational enhancement therapy, may be particularly useful for younger patients, those living alone, and those at risk of relapse (38, 39). We have previously identified 10 ways to potentially improve safety for mental health patients (3). Some of these may function by ensuring that patients get the treatments they need. For example, outreach teams can help ensure treatment receipt and engagement, and specialist services for people with co-occurring disorders can focus on treatment for underlying mental illness as well as substance misuse. Individualized treatment plans with involvement of the family may also help in ensuring that we provide the best treatment we can and minimize the risk of suicide for our patients.