Research and System Learning
Research shows that many people who die by suicide had recent contact with the healthcare system.
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Research shows that many people who die by suicide had recent contact with the healthcare system.
This challenges a common assumption: that suicide primarily occurs among those who never seek help.
In reality, a significant proportion of individuals had already reached out—to therapists, physicians, emergency departments, or inpatient care—before their deaths.
Yet despite this contact, these deaths are rarely examined as opportunities for system learning.
What is often missing is a clear understanding of what happened within care—how risk was assessed, how treatment was delivered, and how individuals experienced that care.
Without this, prevention efforts remain incomplete.
SEEN advocates for a shift in focus: not only encouraging people to seek help—but understanding what happens after they do.
A Significant Proportion Had Contact With Mental Health Services
Research consistently shows that a substantial proportion of people who die by suicide had contact with mental health services prior to their death.
Approximately 25–40% had contact within the year before death—meaning that one in four to nearly one in two individuals had already engaged with the very systems designed to help them.
Many had contact even closer to the time of death.
This directly challenges the idea that suicide is primarily driven by lack of help-seeking.
Instead, it points to a more complex reality:
Access to care does not guarantee safety.
This raises a critical question:
What is happening within mental health care that is not being fully understood?
Sources:
Luoma JB, Martin CE, Pearson JL (2002). Contact with mental health and primary care providers before suicide.American Journal of Psychiatry.
Ahmedani BK et al. (2014). Health Care Contacts in the Year Before Suicide Death. Psychiatric Services.
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Research has shown that current clinical tools used to assess suicide risk have limited ability to accurately identify who will die by suicide.
Large reviews of risk assessment studies have found that most individuals identified as “high risk” do not die by suicide, while many who do die were not classified as high risk during clinical assessment.
This reveals a critical limitation:
Suicide risk is not reliably predictable using current models.
As a result, prevention efforts that rely heavily on risk categorization may fail to identify those who are most vulnerable.
This leads to an important implication:
If we cannot reliably predict who will die, we must also examine what happens to those who do.
Understanding real cases—not just risk profiles—is essential for identifying patterns, gaps, and opportunities for prevention.
Sources:
Franklin JC et al. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research.Psychological Bulletin.
Large MM et al. (2016). Meta-analysis of longitudinal cohort studies of suicide risk assessment among psychiatric patients. PLoS One.
Large MM et al. (2017). The sad truth about suicide risk assessment: why we are still relying on a faulty model. BJPsych Bulletin.
National Academy of Medicine (2020). Improving the Quality of Health Care for Mental and Substance-Use Conditions.
Suicide Risk Is Difficult to Predict
Suicide Occurs During and After Care
Suicide does not occur only outside the healthcare system. It can and does occur during and after treatment.
Research shows that individuals may die by suicide:
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while actively engaged in mental health care
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during inpatient hospitalization
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shortly after discharge
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and while receiving outpatient treatment
Studies have identified the period following discharge from psychiatric care as one of the highest-risk times for suicide, with significantly elevated rates in the weeks and months after leaving treatment.
Suicide has also been documented among individuals actively receiving outpatient care.
Together, these findings lead to a clear conclusion:
Engagement with mental health care does not guarantee safety. Access alone is not enough.
To improve prevention, we must look more closely at what happens within care—how it is delivered, how it is experienced, and how transitions are managed.
Sources:
Ahmedani BK et al. (2014). Psychiatric Services.
Luoma JB et al. (2002). American Journal of Psychiatry.
Chung DT et al. (2017). Suicide rates after discharge from psychiatric facilities. JAMA Psychiatry.
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Treatment-Related Distress Is Not Always Fully Captured
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Even when individuals are actively engaged in mental health treatment, their full experience is not always recognized, documented, or understood.
Clinical assessments often focus on observable symptoms and diagnostic categories. While these are important, they may not fully capture internal experiences such as severe distress, agitation, or changes associated with treatment.
Some individuals report experiencing forms of internal restlessness or discomfort—such as akathisia—that can be intensely distressing and difficult to communicate.
In addition, aspects of the care environment itself—such as loss of autonomy, restrictive settings, or lack of individualized support—may contribute to distress in ways that are not consistently measured or recorded.
These experiences are not always reflected in clinical documentation or included in system-level data.
Without capturing how individuals experience care, important factors related to distress and risk may remain unseen.
Sources:
Barnes TR (1989). A rating scale for drug-induced akathisia. British Journal of Psychiatry.
Hansen L (2001). Akathisia and suicidal behavior. Journal of Clinical Psychiatry.
Royal College of Psychiatrists. Akathisia.
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For some individuals, what is experienced internally may not align with how symptoms are classified in care.
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Known Risk Factors Are Not Always Recognized in Care
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Research has identified certain populations as having elevated risk for suicide, including autistic and neurodivergent individuals.
Studies have found significantly higher rates of suicidal thoughts and behaviors in autistic populations compared to the general population. Factors such as masking, late or missed diagnosis, and differences in how distress is experienced and expressed may contribute to this increased risk.
However, these factors are not always consistently recognized or integrated into clinical assessment and treatment.
As a result, important aspects of an individual’s experience—and their associated risk—may not be fully understood within the care process.
Even when risk is known, it is not always recognized in practice.
A more detailed review of this research is available in: Autism, Neurodiversity, and Suicide Risk.
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When a death occurs in many areas of healthcare, it is followed by a structured review process designed to understand what happened and identify opportunities for improvement.
In the case of suicide, no such standard process consistently exists.
Psychological autopsies—comprehensive reviews that examine an individual’s history, care, and circumstances leading up to death—are not routinely conducted and are not required at a national level.
In most cases, suicide deaths are recorded through death certificates and basic reporting systems, with limited examination of the care pathways leading up to the death.
As a result, critical questions often remain unanswered:
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What care was provided in the weeks and months prior?
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How was risk assessed and managed?
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Were there missed opportunities for intervention?
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How did the individual experience that care?
Without systematic review, patterns across cases are difficult to identify.
These deaths are not consistently examined as part of a learning process.
Without this, opportunities to improve care and prevent future deaths may be missed.
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There Is No Standard Review of These Deaths
Learning From Deaths Improves Prevention
In many areas of public safety, deaths are systematically reviewed in order to understand what happened and improve prevention.
For example:
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Maternal mortality review committees examine deaths related to pregnancy
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Aviation accident investigations analyze crashes to identify system failures
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Child fatality review systems study child deaths to improve protection systems
These review processes have helped identify patterns, strengthen safety systems, and save lives.
Despite the scale of suicide as a public health issue, systematic review of suicide deaths within healthcare systems remains limited in many regions.
Expanding structured case review could help identify patterns and opportunities to strengthen suicide prevention.
Sources:
National Academy of Medicine
Centers for Disease Control and Prevention
National Transportation Safety Board
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These findings point to a critical gap in current approaches to suicide prevention.
When deaths occur among individuals who have already engaged with care, they are not consistently examined as part of a broader learning process.
Without this, patterns remain difficult to identify, and opportunities to improve care and prevent future deaths may be missed.
SEEN exists to bring visibility to these patterns—so that these deaths are not only counted, but understood.