To the Editor: An interesting study by Huisman and colleagues (1) in the January issue described the suicide audit system of the Dutch Health Care Inspectorate. All suicides in the Netherlands are reported to the inspectorate, which follows up on some reports with requests for additional information or with remarks or suggestions for improving services. The study investigated whether the feedback provided by the inspectorate was in agreement with guidelines of the American Psychiatric Association (APA) (2) for assessment and treatment of suicidal patients.
Because the study period was from 1996 until 2006, it is not realistic to expect the responses of the Dutch Health Care Inspectorate to follow guidelines for most of the study years, because the guidelines were not published until 2003. The APA guidelines appear to have been used as a theoretically constructed gold standard. However, this requires further clarification.
As noted in the study, the Dutch Health Care Inspectorate sometimes gave quite detailed feedback to the providers of care, such as emphasizing the importance of telling the patient about an elevated suicide risk in the first weeks after starting antidepressant medication. However, it remains to be seen to what extent American guidelines are applicable in the Netherlands at this level of detail. For example, given restrictions on the possession of firearms in the Netherlands, checking the accessibility of firearms is less important, even though it is repeatedly mentioned in the APA guidelines.
Thirty percent of the persons who committed suicide in the study sample were inpatients. It is important for psychiatric hospitals to check that ligature points are absent (3), although this is not mentioned in the APA guidelines because of the emphasis in this document on the role of individual psychiatrists. Feedback to hospitals from the inspectorate about the need to check for the absence of ligature points would reinforce the role of this agency in suicide prevention.
The findings of the study would have been even more impressive if a standard of care based on the current literature had been used to analyze the responses of the inspectorate, rather than the APA guidelines.
Dr. Hubbeling is a consultant psychiatrist at South West London and St. George's Trust, United Kingdom.
Huisman A, Robben PBM, Kerkhof AJFM: An examination of the Dutch Health Care Inspectorate's supervision system for suicides of mental health care users. Psychiatric Services 60:80—85, 2009
American Psychiatric Association: Practice guideline for the assessment and treatment of patients with suicidal behaviors. American Journal of Psychiatry 160(Nov suppl): 1—60, 2003
Gunnell D, Bennewith O, Hawton K, et al: The epidemiology and prevention of suicide by hanging: a systematic review. International Journal of Epidemiology 34:433—442, 2005