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Suicidal behavior is the result of the complex interaction between many different components that interact over time. Still, traditional study designs operationalize suicidal behavior as static behavior, without any room for individual differences. But it seems times are changing. Novel technology such as data collection via apps and the collaboration with other disciplines such as ecology have resulted in an exciting new line of research within the field of psychopathology. These developments can also have an impact on how we think about, treat, and study suicidal behavior. By introducing complex system science within the field of suicide prevention, we hope to open up a whole range of novel concepts and testable hypotheses that can help us study suicidal behavior from a different perspective: individual, dynamic(al), and contextual.

In this case report, we will present two cases in which the Dutch municipal coroner registered a natural death, but treating psychiatrists doubted the validity of this decision on the grounds of clinical data and investigation. For both cases, we present evidence that deaths likely resulted from suicide, raising serious doubts about the accuracy of the registered cause of death. According to the WHO bulletin on suicide prevention, the national registration of suicide is unsatisfactory in many countries. The Netherlands is listed by the WHO as having one of the most accurate registration procedures. Nevertheless, there are indications that national registration, even in the Dutch system, is not infallible. In this case report, we present several ways in which the registration process is liable to error and evidence for underregistration of suicide rates.

BACKGROUND: Specific and systematic data on health care providers' behaviour is needed to futher improve the care provided to suicidal patiënts in mental health care facilities. METHOD: Explorative observational study of all suicidal incidents (n=5o) that occurred in a Dutch mental health carefacility over a oneyear period. Incidents were evaluated using kehr suïcide, a questionnaire that assesses to what extent health care providers' conduct was compliant to the suicide practice guideline in the context of patients'suicidal behaviour. Associations between health care providers' and patients'features and guideline compliant behaviours of health care providers were calculated by logistic regression models. results: Health care providers showed less guideline compliant behaviour when the patiënt had a psychotic, substance abuse or development disorder or had no axis i disorder. A positive association was found between guideline compliant behaviour and the extent to which the incident had been expected. CONCLUSION: Guideline compliant behaviour of mental health care providers appears to be related to the axis i disorder of patients in a Dutch mental health carefacility. Still, the application of guideline compliant behaviour concerning suïcide incidents shows room for improvement. kehr suïcide is shown to be a helpful tooi for multidisciplinary evaluation of suicidal incidents as it provides specific, ready-made information by which mental health care facilities can guide, examine and adjust suicide prevention policy.The outcomes provide hypotheses that may be examined in future research.

BACKGROUND: Multidisciplinary evaluation of suicide cases effectively decreases the suicide rate in mental health care. A new suicide prevention tool (KEHR) can be used in this connection. KEHR has been developed on the basis of the Dutch multidisciplinary practice guideline on the assessment and treatment of suicidal behaviour. The guideline can serve as a frame of reference for the multidisciplinary evaluation of suicide cases. KEHR aims to provide professionals with a better method for preventing suicide.AIM: To describe and evaluate the recently developed KEHR strategy for reducing the number of suicide cases in mental health care.METHOD: Naturalistic and observational study. In the course of a year 22 out of 23 suicide cases that had occurred in the pilot institution were evaluated with the help of the KEHR system. Outcomes were discussed with members of multidisciplinary teams. Quantitative and qualitative methods were used in the evaluation process.RESULTS: Professionals from the main disciplines involved were very willing to use the new tool and were prepared to reflect on their views on the outcomes. The professionals were ready to learn from the suicide cases. Data collected with the tool provided information that can be used to improve guideline adherence. However, the use of KEHR did not lead automatically to the formulation of adjustments and improvements relating to suicidal patients. A specific procedure for improving individual and team performance needs to be developed and tested thoroughly.CONCLUSION: KEHR is a promising strategy for improving and enhancing the guideline on the diagnosis and treatment of suicidal behaviour of patients in mental health care. Special procedures need to be developed and studied in order to implement the improvements deemed necessary as a result of the pilot study. The KEHR tool (in the Dutch language) is accessible to mental health care workers after online registration (www.mijnkehr.nl).