Prof Louis ApplebyMore than 200 suicide deaths per year now occur in people under mental health crisis teams – three times as many as in in-patients – raising concerns that crisis teams are increasingly used due to pressure on other acute services, particularly in-patient beds, according to a report.

The report, by The University of Manchester’s National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH), found that one third of patients under crisis resolution/home treatment (CRHT) who died by suicide had been using the service for less than a week, and a third had been discharged from hospital in the previous two weeks. The report also questions whether CRHT was the most suitable setting for their care.

Professor Louis Appleby (pictured), director of NCISH, said: “This year’s report reflects the increasing reliance on crisis teams in response to the strains felt by acute mental health services. Our findings suggest that we are accepting too much risk in the home treatment these teams offer, and that the crisis team is now the priority for suicide prevention in mental health.”

The authors also found that more than half the 1,700 mental health patients per year who died by suicide across the UK had a history of alcohol or drug misuse. However, only a small proportion had received specialist substance misuse treatment, suggesting a need for these services to be more widely available, working more closely with mainstream mental health care.

“The report looks at the growing impact of economic adversity,” added Professor Appleby. “More patients who died by suicide were reported as having been unemployed or homeless, and 13% had experienced serious financial difficulties in the previous 3 months. We also identified a rising incidence of suicides by patients who had been in the UK for less than 5 years who may be less well connected to services that could support them."

The team reviewed 20 years of evidence from National Confidential Inquiry research, and found a changing pattern of risk factors facing mental health patients, with higher rates of isolation, recent self-harm, alcohol and drug misuse and economic adversity in those who died by suicide. They also found improvements in some aspects of suicide prevention, such as ward safety and acceptance of medication.

Professor Nav Kapur, head of suicide research at NCISH, said: “The 20-year review has helped us to identify ways in which mental health care is safer for patients. We now know what services can do to reduce suicide risk, for example care planning and early follow-up on discharge from hospital, personalised risk management without routine checklists, and implementing guidance on depression and self-harm.”

Paul Farmer, chief executive of Mind, welcomed the report for indicating the progress being made, especially in reducing inpatient suicides. “But the report also shows there is a long way to go in achieving a goal of zero suicides,” he said. 

“Every year, hundreds of people under the care of mental health crisis teams are ending their lives. It’s a tragedy that anybody who is already in touch with services, and has asked for help, should reach this point. NHS mental health services need to be able respond when people reach out, from early treatment to help prevent people becoming more unwell, to an emergency response that can provide urgent, appropriate, local care when someone is at their most vulnerable.

“A new clear objective to reduce suicide levels by 10% in the Independent Mental Health Taskforce’s Five Year Forward View for Mental Health has been accepted, and [Health Secretary] Jeremy Hunt has rightly put suicide prevention as a key patient safety issue for the NHS as a whole and beyond. It’s vital that the new strategy draws from the learning of this report to put in place a robust plan locally and nationally. There are still too many families who have lost loved ones and we need clear action to reduce these tragedies.”

Homicide

NCISH also report on homicide by people who have been in contact with mental health services. The figures show a fall in patient homicides overall but a possible increase by patients with schizophrenia in England since 2009.

Professor Jenny Shaw, head of homicide research, said: “The numbers are small, so it is difficult to confirm a clear pattern, but it may be that homicides in this group have risen. Services can help by addressing drug and alcohol misuse and ensuring that contact is maintained for those patients who are likely to disengage from mental health care.”

The Mental Health Clinical Review Outcome Programme, delivered by NCISH, is commissioned by the Healthcare Quality Improvement Partnership on behalf of NHS England, NHS Wales, the Scottish Government Health and Social Care Directorate, the Northern Ireland Department of Health, the States of Guernsey and the States of Jersey.