Trigger warning – Patterns before Suicide

I have only cared for one patient in my career so far who died by suicide. We had an excellent relationship, with regular consultations and an honest rapport. Their family often attended too, and we were all clear on how things were going and what we could do together with other services to address the risk. When I was told the patient had died, I was utterly thrown. I couldn’t think of anything else I, or the family or mental health team could have done. There was no change in behaviour or new warning signs that I could see. Our last consultation had been positive and talked about the future. The gratitude and kindness of the family afterwards made me uncomfortable. Fundamentally I felt I had failed, because if I hadn’t, wouldn’t they still be alive? While research in the past has focused on the impact of patient suicide on healthcare professionals, and on identifying specific risk factors or “high-risk” patient groups, these approaches are fairly formulaic and often don’t change between one consultation in general practice and the next. When we are caring for a patient who is always high-risk for suicide, knowing whether that risk is varying from contact to contact can be impossible.

Sometimes we see research papers and think “oh that’s new and fancy”, or “interesting topic”. I saw this one and thought “I wish I’d read this earlier”. The paper published in the BJGP in May 2024 is titled “Primary care consultation patterns before suicide”. It looked at a cohort of over 14,000 patients in England over a period of 18 years, with a control group of up to 40 matched individuals for each patient. It found that escalating or more than monthly consultations are associated with increased suicide risk, (age- and sex -adjusted odds ratio 5.88) regardless of the patients’ sociodemographic background, and the presence (or absence) of known psychiatric illnesses. They were further able to demonstrate even higher risk cohorts which were females (OR 9.50), patients aged 15–<45 years (OR 8.08), patients experiencing less socioeconomic deprivation (OR 6.56), and those with psychiatric conditions (OR 4.57). This pattern can be seen when looking at number of consultations per year, and per month, both of which increased in the patient group. Patients who consulted 2-6 times in the final year of their lives were at 1.47 x high risk of suicide, and those who consulted 7-12 times were at a 2.55 x higher risk than those who consulted once.

Traditionally we are taught to think of young males with little support structures as the highest risk for suicide, but in this cohort who consulted more frequently, it was female patients – still young – but with less deprivation and co-existing psychiatric conditions whose more frequent consultations were particularly indicative. While it’s well-established that men are three times more likely to die from suicide than women, predicting which individuals may need intervention at any one point in time remains challenging.

What were these patients presenting with and does this give us any clue to help narrow down who is at risk? The study found that the most common reasons for the consultations were medication review, depression, and pain in the year before death. These remains the same when the final 3 months before suicide was reviewed, but in the final month the commonest reasons were depression, medication review and requests, and self-inflicted injury.

Unlike previous studies, this one included all types of consultations not just face to face, reflecting a truer picture of current general practice. Whilst we all know that continuity of care can be challenging when trying to achieve the various access targets and meet patient expectations, this paper shows that simply being conscious of and alter to the number of consultations is still a valid marker. It also is a helpful reminder that medication reviews – often delegated to other members of the primary care team, or greeted by us with a sigh of relief for a (relatively) straightforward consultation, can provide a valuable opportunity to ask about mental health and safety plans.

A simple quality improvement project would be to review both your most frequent attenders, and those patients who attendance has incrementally increased in the last 6 months. Sharing this paper with your practice pharmacists who may be tasked with medication reviews, and your reception staff or care navigators to raise awareness of increasing contacts is also an option. And remember our NB Medical Mental health course is available if you need a refresher on the very latest to update your knowledge and support your patients with mental health diagnoses. Support for those affected by suicide is available from Support After Suicide, MIND and Ifucareshare.