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Suicides by mental health patients account for around a quarter of all suicides (Walby et al, 2018). Within services a range of approaches have been developed and implemented to reduce the risk of patient suicides. After every patient death by suicide, a review is carried out to identify recommendations which may assist in preventing future suicides. It is therefore important to identify the most effective methods for implementing these recommendations. The objective of this systematic review, completed in Northern Ireland, was to identify how recommendations from Serious Adverse Incident (SAI) reviews can be effectively implemented to contribute to reducing deaths by suicide within mental health services. Eleven electronic databases were searched for relevant work from 1 January 2005-30 November 2020. Quantitative, qualitative and mixed methods studies were included. A narrative synthesis was carried out of published and unpublished work on the effectiveness of implementing recommendations, after a death by suicide in mental health services. The review, which includes 41 published papers and reports, found that the literature is focused on producing recommendations to reduce future risk of suicide in mental health services. There is a lack of focus on the extent and effectiveness of the implementation of these. Recommendations have often not been tested or operationalised, limiting the translational value of these contributions. Leadership and culture are also identified as key drivers for change in mental health services. This review demonstrates that high quality research is being complete in this area, however, the majority of published research presents recommendations from reviews of mental health patient suicides. There is a lack of research focusing on implementing recommendations and evaluation of implementation, once recommendations have been made., (© 2021 The Authors. Health and Social Care in the Community published by John Wiley & Sons Ltd.)

Aims: To investigate cases of suicide in which there was no healthcare contact, by looking at history of help-seeking and evidence of previous mental health vulnerability. To identify any life events associated with suicide for which individuals did not seek help., Background: Previous research has suggested that non-consultation is the main barrier to suicide prevention among men. Estimates suggest approximately 22% of men who die by suicide have not consulted their GP in the year before their death. Little is known about the lifetime pattern of engagement with services among these individuals and whether or not this may influence their help-seeking behaviour before death., Methods: Coroner records of suicide deaths in Northern Ireland over 2 years were linked to general practice (GP) records. This identified 63 individuals who had not attended health services in the 12 months before death. Coroner's data were used to categorise life events associated with the male deaths. Lifetime mental health help-seeking at the GP was assessed., Findings: The vast majority of individuals who did not seek help were males (n=60, 15% of all suicide deaths). Lack of consultation in the year before suicide was consistent with behaviour over the lifespan; over two-thirds had no previous consultations for mental health. In Coroner's records, suicides with no prior consultation were primarily linked to relationship breakdown and job loss. These findings highlight the limitations of primary care in suicide prevention as most had never attended GP for mental health issues and there was a high rate of supported consultation among those who had previously sought help. Public health campaigns that promote service use among vulnerable groups at times of crisis might usefully be targeted at those likely to be experiencing financial and relationship issues.

Background: Although Primary care is crucial for suicide prevention, clinicians tend to report completed suicides in their care as non-preventable. We aimed to examine systemic inadequacies in suicide prevention from the perspectives of bereaved family members and GPs., Methods: Qualitative study of 72 relatives or close friends bereaved by suicide and 19 General Practitioners who have experienced the suicide of patients., Results: Relatives highlight failures in detecting symptoms and behavioral changes and the inability of GPs to understand the needs of patients and their social contexts. A perceived overreliance on anti-depressant treatment is a major source of criticism by family members. GPs tend to lack confidence in the recognition and management of suicidal patients, and report structural inadequacies in service provision., Conclusions: Mental health and primary care services must find innovative and ethical ways to involve families in the decision-making process for patients at risk of suicide.

Background: Although substance misuse is a key risk factor in suicide, relatively little is known about the relationship between lifetime misuse and misuse at the time of suicide., Aims: To examine the relationship between substance misuse and subsequent suicide., Method: Linkage of coroners' reports to primary care records for 403 suicides occurring over 2 years., Results: With alcohol misuse, 67% of the cohort had previously sought help for alcohol problems and 39% were intoxicated at the time of suicide. Regarding misuse of other substances, 54% of the cohort was tested. Almost one in four (38%) tested positive, defined as an excess of drugs over the prescribed therapeutic dosage and/or detection of illicit substances. Those tested were more likely to be young and have a history of drug misuse., Conclusions: A deeper understanding of the relationship between substance misuse and suicide could contribute to prevention initiatives. Furthermore, standardised toxicology screening processes would avoid diminishing the importance of psychosocial factors involved in suicide as a 'cause of death'., (© The Royal College of Psychiatrists 2016.)

All suicides and related prior attempts occurring in Northern Ireland over two years were analyzed, focusing on number and timing of attempts, method, and mental health diagnoses. Cases were derived from coroner's records, with 90% subsequently linked to associated general practice records. Of those included, 45% recorded at least one prior attempt (with 59% switching from less to more lethal methods between attempt and suicide). Compared with those recording one attempt, those with 2+ attempts were more likely to have used less lethal methods at the suicide (OR = 2.77: 95% CI = 1.06, 7.23); and those using less lethal methods at the attempts were more likely to persist with these into the suicide (OR = 3.21: 0.79, 13.07). Finally, those with preexisting mental problems were more likely to use less lethal methods in the suicide: severe mental illness (OR = 7.88: 1.58, 39.43); common mental problems (OR = 3.68: 0.83, 16.30); and alcohol/drugs related (OR = 2.02: 0.41, 9.95). This analysis uses readily available data to highlight the persisting use of less lethal methods by visible and vulnerable attempters who eventually complete their suicide. Further analysis of such conditions could allow more effective prevention strategies to be developed., (© 2014 The American Association of Suicidology.)