To Örebro University

Background: Heart diseases are among the leading causes of disease burden worldwide with often a large impact on the lives of the affected individuals. The association between heart disease and depression is well-known and elevated suicide risk has been demonstrated in several types of heart disease. The aim of this study was to investigate what health care contacts individuals with heart disease who died by suicide had in the two years prior to death, compared to those without, and whether signs of mental health problems were recognised and addressed.

Methods: As a part of a larger project, medical records from all care settings (primary care, hospital records etc.) for the last two years for all individuals who died by suicide in Sweden in 2015 were evaluated, n = 1,179. In this sub-study, we investigated healthcare contacts for the individuals with heart disease, n = 124, and compared these to those without, n = 1,055. We analysed the clinical characteristics of their last visit in all health care settings, and demographic and clinical factors contributing to recognition of depression when outside of psychiatric specialist care.

Results: The individuals with heart disease had more healthcare contacts than those without during the last two years before death. During their final week of life, 58% were in contact with health care, compared to 32% for those without (p < .001). The contacts took place primarily in primary care and somatic specialist care. At the last doctor’s visit, 51% had symptoms of depression and/ or anxiety recorded, but less than 25% had an action taken due to this if the visit was in primary care or somatic specialist care. Suicide risk was assessed as elevated in 15%, but only a small proportion of these in primary care (3%) and somatic specialist care (4%).

Conclusion: The individuals with heart disease had many healthcare contacts before dying by suicide, especially in primary care and somatic specialist care, yet their mental health problems were not sufficiently identified or treated. This points to a need to improve the recognition and treatment of depression in these settings to support suicide prevention in individuals with heart disease.

BACKGROUND: The period immediately following psychiatric inpatient care is recognized as a time of elevated risk of suicide, yet little is known about factors that influence how soon suicide occurs after discharge.

AIM: To examine the timing of suicide among persons after psychiatric discharge and identify sociodemographic and clinical factors associated with a shorter time to death by suicide.

METHODS: We included all adults in Sweden who died by suicide in 2015 and who had been discharged from psychiatric inpatient care during the last three months of life (n = 140). Sociodemographic and clinical variables were extracted from electronic medical records, including contextual factors from the last hospitalization (involuntary care, documented suicide risk, unplanned discharge). Time to suicide was modelled using stratified Cox proportional hazards regression.

RESULTS: The median time from discharge to death was 32 days. Older age was the only background factor independently associated with a shorter time to suicide; each additional 10 years of age was associated with shorter time to suicide, as indicated by an increased unadjusted hazard ratio (uHR) of 1.26 (95% CI: 1.12-14.2, p < .001). A diagnosed neurotic, stress-related and somatoform disorder (ICD-10 code F40-F49) was associated with a longer time to suicide (uHR = 0.68 (0.47-0.98), p = .036), although this association was not statistically significant when adjusting for age (aHR 0.82, 0.56-1.20, p = .310). Previous suicide attempts, sex, substance use disorder and depressive disorders were not associated with time to suicide. Neither involuntary care nor the presence or absence of a formal suicide risk assessment during inpatient stay predicted earlier suicide. Unplanned discharges were likewise unrelated to the time to suicide.

CONCLUSIONS: Among people who died by suicide within three months of psychiatric discharge, only older age independently predicted a shorter time to suicide. The absence of clear signals-particularly from routinely collected risk assessments-suggests that timely, universal follow-up may be more appropriate than attempts to target aftercare on the basis of standard risk markers.

CLINICAL TRIAL NUMBER: Not applicable.

OBJECTIVES: To evaluate whether suicidality was documented prior to suicide in patients in contact with specialised somatic healthcare providers for physical conditions and to identify factors related to such documentation.

DESIGN AND SETTINGS: Retrospective cohort study in which medical records from specialised somatic (non-psychiatric) healthcare services (internal medicine, infectious disease, surgery, urology, etc) in 20 of Sweden's 21 regions were reviewed up to 2 years before suicide.

PARTICIPANTS: Those who died by suicide in Sweden 2015 and had received specialised somatic healthcare for a diagnosed physical condition were included, n=468 (331 men and 137 women).

THE OUTCOME VARIABLE: Documentation of suicidality (ie, death wishes, suicidal thoughts, plans, attempts and notations of known suicidality or elevated suicide risk). Potential associations of patients' characteristics and clinical factors with the outcome were tested in logistic regression models.

RESULTS: Of the 468 patients, 111 (24%) were positive for the outcome variable Documentation of suicidality, regardless of whether they were assessed as suicidal or not. Elevated suicide risk was noted in 27 patients (6% of the total cohort). Multivariate logistic regression analysis showed that experience of distress (OR: 4.81; 95% CI: 1.96 to 11.81), contact with psychiatric services (OR: 4.68; 95% CI: 2.60 to 8.43), psychiatric comorbidity (OR: 4.33; 95% CI: 2.41 to 7.76) and female sex (OR: 2.91; 95% CI: 1.68 to 5.06) were independently associated with documentation of suicidality. A third (36%) had a doctor consultation in specialised somatic healthcare during their last month of life. Of these, 17% were assessed for suicidality, and elevated suicide risk was noted in 7%.

CONCLUSIONS: Documentation of suicidality was observed in one quarter of patients who received specialised somatic healthcare for physical conditions and subsequently died by suicide. These results indicate a need to increase clinician awareness of suicidal issues and assessments and to integrate questions about mental health into specialised somatic practice.

BACKGROUND: The therapeutic relationship has been identified as essential for ensuring high-quality care in psychiatric outpatient services, as highlighted in several studies. This study focuses on the content of interactions between patients and staff in psychiatric outpatient care, as well as the quality of care provided, as perceived by the patients. AIM: The aim of this study is to explore the relationship between these interactions and aspects of the perceived quality of care from the perspective of patients in psychiatric outpatient services.

METHODS: A sample of 706 patients from psychiatric outpatient clinics in Sweden completed the Verbal and Social Interaction Outpatient (VSI-OP) and the Quality in Psychiatric Care-Outpatient (QPC-OP) instruments. A structural equation model was conducted to explore these associations. The study was approved by the Regional Ethical Review Board in Uppsala, Sweden (Dnr. 2018/186).

RESULTS: The model revealed that the staff showing an interest in the patients' feelings, experiences and behaviour influences the patients' perceived quality of participation through an intricate network of mediator variables, including the staff's ability to establish a relationship, a good encounter, support and a high level of information to the patients. High levels of Participation/Empowerment indicate a high level of quality of care in a psychiatric outpatient context.

IMPLICATION FOR PRACTICE: The presented model provides an understanding of the associations between staff and patient interactions and perceived quality of care and sheds light on important aspects of quality of care from the perspective of the patients.

Objectives: Individuals who die by suicide often consult their general practitioners (GPs) in their final weeks of life. The aim of this study was to gain a deeper knowledge of the clinical characteristics and GP assessments and treatments among individuals who consulted their GPs during the month preceding suicide. Further, we compared these features in those with and without contact with psychiatric services (PC and NPC, respectively) during the two years that preceded the suicide.

Design: A nationwide retrospective explorative study investigating medical records.

Setting: Primary care in Sweden.

Participants: Individuals who died by suicide in Sweden in 2015 with a GP visit within 30 days of death.

Results: The study cohort corresponds to one fifth (n = 238) of all suicides that occurred in Sweden in 2015 (n = 1179), representing all those with available primary care records showing contact with a GP during the final 30 days of life (NPC: n = 125; PC: n = 113). The mean age was 58 years +/- 19. Patients in the NPC group were older (NPC: 63 years +/- 19 vs. PC: 53 years +/- 18, p < 0.0001) and presented psychiatric symptoms less often (NPC: 50% vs. PC: 67%, p < 0.006). Somatic symptoms were as common as psychiatric symptoms for the whole sample, being present in more than half of individuals. Suicide risk was noted in only 6% of all individuals. Referral to psychiatric services occurred in 14%, less commonly for the NPC group (NPC: 6% vs. PC: 22%, p < 0.001). Cardiovascular or respiratory symptoms were noted in 19%, more often in the NPC group (NPC: 30% vs. PC: 6%, p < 0.001), as were diagnoses involving the circulatory system (all 10%, NPC:14% vs. PC: 5%, p < 0.020).

Conclusion: A high level of somatic symptoms was observed in primary care patients both with and without psychiatric contact, and this might have influenced GPs' management decisions. Psychiatric symptoms were noted in two thirds of those with psychiatric contact but only half of those without. While GPs noted psychiatric symptoms in over half of all individuals included in the study, they seldom noted suicide risk. These findings highlight the need for increased attention to psychiatric symptoms and suicide risk assessment, particularly among middle-aged and older individuals presenting with somatic symptoms.

Strengths and limitations of this study: The National Cause of Death Register has excellent coverage of suicide deaths and access to medical records was very good. The medical record review provided detailed information regarding primary care utilization before death by suicide. Because of the lack of statistical power, due to the limited number of persons with GP contact during the last month of life, we chose not to correct for multiple comparisons. Our study approach did not capture the reasons behind GPs' documentation of elevated suicide risk. No systematic inter-rater reliability (IRR) testing was made, however, reviewers received training and continuous support from the research group.

Objective: To investigate the relationship between perceived mental health service provision and quality of life (QoL) as perceived by patients in psychiatric outpatient care.

Methods: A total of 373 adult patients registered at 15 psychiatric outpatient clinics in three regions in central and southern Sweden were included in the study. Survey data were collected using a questionnaire on mental health service provision, symptom severity, recovery, clinical diagnosis, sociodemographics (serving as independent variables) and QoL (serving as the dependent variable). Three aspects of mental health service provision were used: patients’ perceived quality of care, perceived staff-patient interaction, and patient reported psychiatric treatments. Structural equation modelling was used to model the relationship among the variables.

Results: Variables in mental health service provision showed few direct associations with patients’ perceived QoL. Instead, the associations of mental health service provision on QoL were mainly mediated through symptom severity and recovery. These relationships were retained after adjusting for sociodemographic variables and clinical diagnoses. The final model achieved excellent goodness of fit (χ2 = 49.502, p = 0.230, RMSEA = 0.020, CFI = 0.997 and a SRMR = 0.024).

Conclusion: This study shows that mental health service provision is associated with patients’ perceived QoL; however, this association is mostly indirect and mediated by reduced symptom severity and increased recovery. This finding can help inform the design of future interventions to enhance service provision to improve patients’ QoL.

OBJECTIVE: Previous literature has suggested that identifying putative differences in health care seeking patterns before death by suicide depending on age and gender may facilitate more targeted suicide preventive approaches. The aim of this study is to map health care utilisation among individuals in the two years prior to suicide in Sweden in 2015 and to examine possible age and gender differences.

METHODS: Design: A retrospective explorative study with a medical record review covering the two years preceding suicide.

SETTING: All health care units located in 20 of Sweden's 21 regions.

PARTICIPANTS: All individuals residing in participating regions who died by suicide during 2015 (n = 949).

RESULTS: Almost 74% were in contact with a health care provider during the 3 months prior to suicide, and 60% within 4 weeks. Overall health care utilisation during the last month of life did not differ between age groups. However, a higher proportion of younger individuals (< 65 years) were in contact with psychiatric services, and a higher proportion of older individuals (≥ 65 years) were in contact with primary and specialised somatic health care. The proportion of women with any type of health care contact during the observation period was larger than the corresponding proportion of men, although no gender difference was found among primary and specialised somatic health care users within four weeks and three months respectively prior to suicide.

CONCLUSION: Care utilisation before suicide varied by gender and age. Female suicide decedents seem to utilise health care to a larger extent than male decedents in the two years preceding death, except for the non-psychiatric services in closer proximity to death. Older adults seem to predominantly use non-psychiatric services, while younger individuals seek psychiatric services to a larger extent.

There is a knowledge gap about predictors of treatment outcomes in alcohol use disorder (AUD) in socially stable women. This study examined factors that may predict abstinence 12 months after the end of treatment for AUD in socially stable women. Fifty-seven women with AUD participated in 12-month follow-up. Information about sociodemographic, alcohol-related, psychiatric symptoms, psychological functioning, and participants' treatment goals and ability to change alcohol habits were gathered from structured interviews and self-report instruments. Predictors for abstinence at the 12-month follow up were calculated by univariable and multivariable logistic regression models. Significant predictors for abstinence were having no history of childhood abuse (OR: 8.13; 95%CI: 2.22-29.75; p < .01) and a goal of abstinence at the end of treatment (OR: 15.17; 95%CI: 3.45-66.69; p < .001). Most participants (>60%) achieved their goals of abstinence or low-risk drinking. The results highlight the significance of identifying patients with experiences of childhood abuse, since such experiences may adversely affect the outcome of AUD treatment. Our findings also emphasize the importance of patients' own goals of abstinence, since it resulted in the most stable outcome. Treatment could, therefore, also focus on motivating individuals to aim for abstinence.

We interviewed 20 adolescents who were coercively placed in residential or psychiatric care. The aim was to explore their views on the way staff relate and perform their duties, favorable characteristics in staff, consequences of different treatment from staff and their safety experiences. Thematic analysis identified the following themes: Situational triggers of frustration; Care-based; rule-based; or passive-avoidant interaction styles toward adolescents and their responses; Adolescents' reflections about staff's interaction styles; and the Consequences on the unit atmosphere depending on different interaction styles toward the adolescents. Adolescents preferred staff who showed them respect and a clear wish to make life easier.

BACKGROUND: Research is required to identify those psychiatric interventions with a protective effect against suicide. The overarching aim of the current study was to examine whether completed suicide in psychiatric patients in a Swedish population was associated with the quantity and nature of previous medical and psychosocial treatment interventions.

METHODS: This retrospective case-control study (n = 308) compared a group of deceased psychiatric patients with matched controls. For every case of suicide, a control was found within psychiatry that matched according to sex, age, and primary psychiatric diagnosis. A stepwise forward logistic regression model with suicide as the dependent outcome variable was used.

RESULTS: Receiving pharmacotherapy combined with psychotherapy [OR: 0.44 (95% CI: 0.226-0.876), p = 0.019] and a higher number of outpatient visits in psychiatry [OR: 0.99 (95% CI: 0.982-0.999), p = 0.028] were negatively associated with suicide. These associations were still significant after controlling for previous serious suicide attempts and somatic comorbidity.

CONCLUSIONS: Frequent visits and pharmacotherapy combined with psychotherapy seem to be important for preventing suicide in psychiatric patients. The reasons for not receiving such therapy are important issues for further study.