This study shows that two-thirds of those who died from suicide in Aust-Agder and Vest-Agder counties in the period 2004–2013 had been in contact with mental health care or interdisciplinary specialised addiction services at any point during their lifetime. Slightly less than half had been in such contact during the last year prior to their suicide. Approximately one-third of all those who committed suicide had been in contact with mental health care or interdisciplinary specialised addiction services during the last 30 days before the suicide took place.
The proportion with contact represents a minimum estimate, since some may have lived and received treatment in other counties without having received any treatment after relocating to the Agder region. Nor do we have any overview of the contacts that these patients may have had with psychiatrists or psychologists in private practice, but the number is likely to be low, since there are very few professionals in private practice in the Agder counties.
The proportion that had been in contact during the last year prior to their suicide is higher than what has been found in the UK (14) and other countries (12), while the proportion in this study corresponds to findings made in a previous Norwegian study (16). We found a tendency towards an increasing proportion with contact through the period 2004–2013. For such a small catchment area, this is an uncertain finding, although it corresponds to the trend that was observed in the UK over the same period (19).
The observation that a greater proportion had contact with the specialist health service in Norway compared to the UK can be interpreted in different ways. This may be due to differences in the forms of organisation, design and consumption of health services. Moreover, it can be an indication that the health services in Norway are more dispersed and more easily available, for example as a result of the escalation plan for mental health care (20).
Data from The National Confidential Inquiry in the UK shows that the suicide rate declines in areas where the national recommendations for expansion of the services are followed, according to a study that compared suicide rates in 1998 and 2006 in light of the measures that had been implemented in various regions. The measures that had the greatest impact were a 24-hour, easily accessible health service for people in crisis, measures for persons with dual diagnoses and an interdisciplinary review in the aftermath of each suicide incident with a view to learning (21).
In Norway as well, the health authorities have initiated national initiatives for suicide prevention in the health services, such as the National guidelines for suicide prevention in mental health care (22) and a national campaign for patient safety directed at acute wards (23). These measures came into force much later than their UK equivalents, and their effects have not yet been systematically evaluated.
There were no significant differences in terms of gender distribution between the group that had been in contact in the final year and the group that had had no contact with mental health care or interdisciplinary specialised addiction services. There was a slight tendency towards a lower average age in the group with no contact; the age distribution shows that there was a larger proportion of people younger than 30 years in this group. Special measures should therefore be considered for this group in particular, to ensure increased contact with the health services.
More than half of the patients had a history of illness dating back more than five years. This must be deemed a conservative estimate, since the estimation of the duration is fraught with some uncertainty because some may have attended treatment in other health enterprises. Four of every five had been admitted to an inpatient mental healthcare unit or interdisciplinary specialised addiction services at least once during their lifetime. In combination with the distribution of diagnoses, this indicates that a major proportion of the patients suffered from serious and to some extent long-term mental health problems.
Approximately one in every six patients who had undergone treatment during the last year took their life during hospitalisation, while one in every five took their life within one month after discharge from an inpatient unit. The proportion of suicides during hospitalisation is higher than what was found in the UK (19). The reason could be that patients in Norway are more frequently admitted to inpatient facilities in general. Another reason could be that in recent years, special emphasis has been placed on suicide prevention during hospitalisation in the UK. This has resulted in a 60 % reduction in this group (19). National guidelines exist also in Norway in this area (22), but their impact is as yet unknown.
Approximately one-third of the patients who had been in contact with treatment institutions over their final year were no longer in treatment in the specialist health service at the time of their suicide. On average, this group was older than the group that remained in treatment. The proportion suffering from psychotic disorders was greater in the group that remained in treatment and the proportion with adjustment disorders was greater in the group that had discontinued their treatment. As regards the psychotic disorders, the explanation could be that these patients frequently receive long-term follow-up by the specialist health service.
The large proportion of persons with adjustment disorders in the group that had discontinued their treatment may stem from a number of issues. Adjustment disorders are by definition time-limited, so it should come as no surprise to find more patients with completed therapies in this diagnostic group. Another explanation could be that insufficient diagnostic assessment was made to detect other mental disorders, such as depression, addiction or personality disorders.
One area for further studies could be to validate the use of adjustment disorders in this context, especially in delimiting personality disorders, post-traumatic stress disorder and depression, and study specific risk factors for suicide in this population.
A strength of this study is that it was based on the entire population of two counties. Sørlandet Hospital has a high coverage rate in mental health care and interdisciplinary specialised addiction services, and all treatment provided by the health trust is documented in a shared electronic records system. For people who did not have an electronic patient record, searches were undertaken in the paper-based records. Old records archives are exposed to a somewhat higher risk of archive misplacement, meaning that we cannot know for certain that all relevant records were identified. The Cause of Death Registry provides a good overview of suicides in Norway, and we regard the identification procedure at Sørlandet Hospital as reliable.
The weaknesses of the study are primarily associated with our basing the data collection on records whose main purpose is not research. Some variables, such as the main diagnosis, therefore have uncertain validity. The study's design is primarily descriptive, and the methods of inferential statistics that have been used in the analyses must be assessed in this context. For this reason, the study's findings ought to be validated, for example through an approach based on hypothesis testing.
In the period studied, the suicide rate in the Agder region did not differ significantly from the national rate. However, for many years Sørlandet Hospital has had a somewhat higher proportion of the population as patients in mental health care and interdisciplinary specialised addiction services (24), meaning that the contact estimates for persons who commit suicide may be somewhat elevated. With this reservation, it is reasonable to assume that the results from this study can be generalised to Norway as whole.