Suicide and Community Care

¹ Senior Registrar, Children's Department, The Maudsley Hospital, London, S.E.5

Community treatment of the mentally ill has become fashionable, but may carry with it risks as well as advantages. An important function of a Mental Health Service is the prevention of suicide amongst the population as a whole as well as specifically amongst its patients. Al-though a community-oriented service may in some ways be more effective and attractive than a hospital-oriented one, it may be less protective of its patients, and needs to be more sensitive to their individual needs.

In the present work the incidence of suicide in the population of the area of the Community Psychiatric Service at Chichester and amongst patients within a year of contact has been studied, comparing two five-year periods (I and II) before and after the introduction of Community Care methods. Some general findings are also reported.

Amongst in-patients there was no change in the suicide rate of about 200 per 100,000.

The suicide rate amongst all psychiatric patients within a year of contact is reported: it was 240 per 100,000 in period I and 169 per 100,000 in period II; though not statistically significant, the fall is probably related to the increase in the number of patients in contact with the psychiatric services in period II, and it is thought that the extra patients are less suicidal rather than that the service has become generally more effective in preventing suicide.

Patients were 24.6 times as liable to commit suicide than non-patients in period I (15.5 times in period II); the ratio is lower for women than for men.

In the area population as a whole there was little change in the suicide rate between the two periods, especially when variations in the national suicide rate are taken into account. Even the change amongst men over 60, from 31.2 to 21.5 per 100,000, did not reach statistical significance.

The proportion of suicides in contact within a year of death has not changed significantly, averaging 23.5 per cent. Such contact was less frequent amongst men (18.6 per cent.) than amongst women (30 per cent.).

Amongst female suicides over 60, none in period II had been seen by the Service within the past year, compared with 44.5 per cent. in period I. Suicides within a year of contact can be regarded as "failures" of the Service in suicide prevention. The incidence of these in the area population has fallen, for age over 60, from 4.24 per 100,000 to zero. These changes reach statistical significance and suggest that, while the introduction of Community Care has had no clear effect on suicide in the whole area population or amongst younger patients, it may have protected some elderly patients from suicide. Possible reasons for the difference in effect at different ages are discussed.