Suicide prevention: is it resources?
A hypotheses in JAMA psychiatry recently was that the number of beds (a proxy, albeit a poor one, for Mental Health Funding) has cecrased at the same time the suicide rate has increased.
This is a correlation. But is it causative?
The closure of most US public mental hospital beds and the reduction in acute general psychiatric beds over recent decades have led to a crisis, as overall inpatient capacity has not kept pace with the needs of patients with psychiatric disorders.1 Currently, state-funded psychiatric beds are almost entirely forensic (ie, allocated to people within the criminal justice system who have been charged or convicted). Very limited access to nonforensic psychiatric inpatient care is contributing to the risks of violence, incarceration, homelessness, premature mortality, and suicide among patients with psychiatric disorders. In particular, a safe minimum number of psychiatric beds is required to respond to suicide risk given the well-established and unchanging prevalence of mental illness, relapse rates, treatment resistance, nonadherence with treatment, and presentations after acute social crisis. Very limited access to inpatient care is likely a contributing factor for the increasing US suicide rate. In 2014, suicide was the second-leading cause of death for people aged between 10 and 34 years and the tenth-leading cause of death for all age groups, with firearm trauma being the leading method.2,3
Currently, the United States has a relatively low 22 psychiatric beds per 100?000 population compared with the Organisation for Economic Cooperation and Development (OECD) average of 71 beds per 100?000 population. Only 4 of the 35 OECD countries (Italy, Chile, Turkey, and Mexico) have fewer psychiatric beds per 100?000 population than the United States. Although European health systems are very different from the US health system, they provide a useful comparison. For instance, Germany, Switzerland, and France have 127, 91, and 87 psychiatric beds per 100?000 population, respectively.
Now correlation is not causation. The correlation was replicated nation wide in the USA is one paper, but not by state and a subsequent letter argues that this hypothesis is false because it should work at the state level. I’m not sure if the author has considered that people can move, particularly in the northeast, between states.
I do know that people move around the South Island — and that is 1200 km north to south: or, more importantly, given the recent earthquakes, 12 to 16 hours driving.
The availability of psychiatric hospital beds and substance abuse beds in short-term general hospitals was not causally related to suicide rates. Some between-state associations were found; however, they were confounded with other state-level differences. Yoon and Bruckner found an overall inverse association between the state-level availability of public psychiatric hospital beds and suicide rates; however, our analysis suggests that this was a between-state association, and that changing the availability of psychiatric hospital beds within a given state will not reduce suicide rates. Changes in the number of substance abuse beds and amount of mental health expenditures were similarly unrelated to within-state changes in suicide rates.
Our study is limited by the lack of available data on long-term psychiatric hospitals and stratification by public and private hospitals.
Our findings indicate that attention should focus on determining how existing psychiatric beds are used rather than their absolute number. What are the proportions of high-risk patients being treated as outpatients vs inpatient, and how do their suicide rates compare after adjusting for risk profiles? Suicide risk is linked to rates of the diagnosis of major depression and how effectively it is treated at the outpatient level. Given that the US Centers for Disease Control and Prevention data on suicidal behavior, psychiatric diagnoses, and treatment in 18 states indicate that from 2005 to 2010, the rate of people receiving psychiatric treatment before dying of suicide was only 28.5%, there is considerable room for improvement. By focusing on hospital bed capacity, we may miss more fundamental deficits in detecting and treating patients at risk for suicide.
The assumption that we can do better needs to be challenged. The number of people being seen within the NZ mental health system (which is primarily outpatient) is increasing. The number of beds is not. SImple math will give you an estimate of the rate of admissions: it does not help with bed numbers.
While the number of people being seen is increasing, the suicide rate is going up. Although the rate of suicide in non patients is at least ten times lower than among patients, only a small proportion of the population are seen by psychiatric services. Improving service delivery will not affect those who do not have a psychiatric condition. This is from the NZ ministry of health.
It may not be about beds. Correlation is not causation. The suicide rate may have more to do with the optimism of a society and the level of social support and trust within the community. Most people who die by suicide are not under mental health care, at least in NZ>
But our suicide rate is twice the death rate from road crashes. We should never be complacent. Each suicide lessens us.