Title Suicide with psychiatric diagnosis and without utilization ofpsychiatric service

Background: Considerable attention has been focused on the study of suicides among those who have received help from healthcare providers. However, little is known about the profiles of suicide deceased who had psychiatric illnesses but made no contact with psychiatric services prior to their death. Behavioural model of health service use is applied to identify factors associated with the utilization of psychiatric service among the suicide deceased. Methods: With respect to completed suicide cases, who were diagnosed with a mental disorder, a comparison study was made between those who had (contact group; n = 52; 43.7%) and those who had not made any contact (non-contact group; n = 67; 56.3%) with a psychiatrist during the final six months prior to death. A sample of 119 deceased cases aged between 15 and 59 with at least one psychiatric diagnosis assessed by the Structured Clinical Interview for DSM-IV-TR (SCID I) were selected from a psychological autopsy study in Hong Kong. Results: The contact and non-contact group could be well distinguished from each other by “predisposing“ variables: age group & gender, and most of the “enabling”, and “need” variables tested in this study. Multiple logistic regression analysis has found four factors are statistically significantly associated with non-contact suicide deceased: (i) having non-psychotic disorders (OR = 13.5, 95% CI:2.9-62.9), (ii) unmanageable debts (OR = 10.5, CI:2.4-45.3), (iii) being full/partially/self employed at the time of death (OR = 10.0, CI:1.6-64.1) and (iv) having higher levels of social problem-solving ability (SPSI) (OR = 2.0, CI:1.1-3.6). Conclusion: The non-contact group was clearly different from the contact group and actually comprised a larger proportion of the suicide population that they could hardly be reached by usual individual-based suicide prevention efforts. For this reason, both universal and strategic suicide prevention measures need to be developed specifically in non-medical settings to reach out to this non-contact group in order to achieve better suicide prevention results. Background Retrospective psychological autopsy studies on completed suicides found that 60 to 90 percent of the suicide cases suffered from psychiatric illnesses prior to death [1-4]. However, a large proportion of suicides, ranging from 50 to 75 percent of suicides did not make contact with mental health services prior to their deaths [1,3-9]. This phenomenon has been suggested as one of the significant reasons of why suicide prevention efforts targeted on people with mental illnesses, i.e. medical treatment for people with depression, have been very limited in reducing suicide rates [10,11]. Therefore, in order to further reduce suicide rates, we must consider offering effective help not only to those currently being treated by our healthcare system, but also those who are currently not receiving care (namely the non-contact group). Unfortunately, many record-based studies on completed suicides can only study the psychiatric and psycho-social profiles of suicide cases that are known to the healthcare system [5,12-14]. Little was known about the profiles of the non-contact group as well as the factors surrounding their deaths [15]. It is imperative to investigate the characteristics and profiles of the non-contact group using a psychological autopsy methodology. Among the paucity of studies that have investigated the non-contact group, some findings are noteworthy. Booth and Owens’ review paper on five record-based studies that investigated the non-contact group * Correspondence: flawhk@hku.hk † Contributed equally Department of Social Work and Social Administration, The University of Hong Kong, Pokfulam, Hong Kong SAR, China Law et al. BMC Public Health 2010, 10:431 http://www.biomedcentral. com/1471-2458/10/431 © 2010 Law et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. comprised between 65 to 86 percent of all suicides and that males were significantly less likely than females to seek help [16]. Another study using linked populationbased data in Taiwan showed that a much lower proportion of those committing suicide had received mental healthcare services within one year prior to their death (22.2% of 19 426 suicides). Those who had made no contact with a mental service professional tended to be male and aged over 55 [17]. Specifically, those who committed suicide by poisoning from charcoal burning in Taiwan had significantly fewer contacts with psychiatrists (18%) than those suicides by hanging (25%) and poisoning (23%) [18]. Owens and colleagues investigated the psychiatric and psycho-social aspects of the non-contact suicide group by comparing them with live controls [19]. They found the factors which predicted non-contact suicides were remarkably consistent with what was already known about suicides in general such as a previous attempted suicide, current or past mental illnesses, social and interpersonal problems. They also found that there was a markedly lower rate of mental illness (68%) among the non-contact suicide group than that of other psychological autopsy studies (90%). The authors, however, failed to consider mental illness as a major necessity in seeking care. Without considering mental illness as a need as well as a primary reason to seek mental health services and controlling this as the major variable in both suicide and live control groups, they were actually noncompatible in terms of the nature of the “need“ of seeking help for medical treatment. In accordance with the Behaviour Model of access to medical care by Andersen [20], the “perceived” or “evaluated” need of a person should be considered as a precedent factor of whether or not it is important and a strong enough motive to seek professional help [20]. Therefore, it is crucial to gain a better understanding about psychiatric serviceuse among suicides with mental illness(es), before we suggest whether or not suicide rates can be reduced by improved psychiatric care [21,22]. The basic assumption of the behavioural model is that access to health care is a rational decision-making process during which “People’s seeking healthcare services is a function of their predisposition to use those service factors, which enable or impede that use and the need for care” (pg. 1) [20]. ‘Predisposing characteristics’, for instance, include age, gender, genetic and psychological characteristics, social structure (i.e. education, ethnicity, social networks, interactions and culture) as well as health beliefs, values and general knowledge about health care and services. These are all important determinants that can directly affect one’s perception of need for and the actual use of health services. “Enabling resources” are generally referring to the income and wealth available to individuals to pay for services, or if they have health insurance coverage, regular source of care, and travel time to and waiting time for care [23]. It is known that unmet need among people with mental illness for mental health service is likely associated with disadvantaged groups, such as those with low incomes, and those without insurance [24]. Therefore, financial resources or means of getting financial support are the basic components that can facilitate one’s access to healthcare services. The third important component is ‘need’ which itself has two dimensions: perceived need and evaluated need. The former is the perception of how people view and experience their own general health and functional state and whether or not they find their own problems severe enough to seek professional help (help-seeking) and be compliant to treatment. The later is assessed by professionals and may not agree with a person’s perceived need. It is closely related to the type and amount of treatment provided to a person after they seek help from a medical provider [20,25,26]. Besides, types of psychiatric diagnoses may also explain different level of health service use. Research showed that people who suffered from psychotic disorders showed high levels of mental health service use as well as community-based health service use in comparing to those with non-psychotic disorders [27,28]. Based on the behavioural model, this study will investigate the psychiatric and psycho-social characteristics of suicide deceased who were diagnosed with mental illnesses but did not make contact with any psychiatrist. It is hypothesized that the contact & non-contact group of suicide can be distinguished by “predisposing“, “enabling“ & “need“ variables as suggested by the behavioural model. We utilised the data collected from a psychological autopsy study of suicides in Hong Kong between 2003 and 2005 to test our hypothesis. Comparisons will be made between those who had (contact group) and those who had not (non-contact group) visited any psychiatrist during the final six months prior to death. Methods All suicide cases from the psychological autopsy study were identified from deaths registered as “suicide” by the Coroner in Hong Kong and coded from X60 to X84 under the Tenth International Classification of Disease (ICD-10) of the World Health Organization [29]. The study investigated 150 Chinese suicide cases aged 15 to 59 against a comparison of 150 live controls between September 2003 and December 2005. The study was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (HKU/HA HKW IRB) and the Ethics Committee of the Department of Health, Hong Kong Law et al. BMC Public Health 2010, 10:431 http://www.biomedcentral. com/1471-2458/10/431 Page 2 of 11