Summary in English

In 2023 and 2024, the Norwegian Board of Health Supervision conducted a nationwide supervision of suicide prevention in adult mental health services. The overarching theme of the supervision was whether adult mental health services provide safe and high-quality care for patients with depression. To answer this, we investigated the following: 

• Specialist assessment within the first 24 hours 
• Gathering relevant information from next of kin 
• Diagnostic evaluations 
• Communication of diagnostic evaluations and treatment options 
• Evidence-based treatment 
• Information flow between support staff and the responsible clinician 
• Safe discharge 

These measures have proven to be effective in the treatment of patients with depression and should be implemented in specialist health services. 

In addition to examining practice in these seven areas, we also investigated how hospitals systematically and continuously work to identify risk areas in the treatment of patients with depression, implement interventions, evaluate the effectiveness of those interventions, and adjust them based on the evaluation.

Main Findings from the Supervision 

The supervision uncovered several critical areas that require attention and improvement in order to enhance patient safety and reduce the risk of suicide among patients with depression. 

• Five out of ten hospitals did not have an established practice to ensure that patients with depression were assessed by a specialist promptly. This may result in serious conditions going undetected, potentially causing cascading failures throughout the treatment process. 
• In two hospitals, information from next of kin was not systematically collected, and in six others, such information was not adequately documented. This can lead to important information not being considered during treatment. 
• In seven hospitals, there were no provisions to ensure that patients received treatment based on updated diagnostic evaluations. This can result in ineffective treatment. 
• The discharge process was deemed unsafe in five out of ten hospitals, including deficiencies in planning and coordination with services responsible for follow-up care after discharge. 
• Inadequate governance and leadership increase the risk of failure in the care provided to patients with depression. There is a need for clear objectives and systematic efforts to ensure the quality of treatment. 

Lack of specialist assessments and diagnostic evaluations may lead to incorrect treatment, while shortcomings in the discharge process may increase the risk of suicide after patients are discharged from the hospital. The violations uncovered during the supervision pose a risk that patients are discharged without having received appropriate treatment with a suicide-preventive effect and without sufficient support to handle potential new crises after discharge. By implementing improvements in these areas, hospitals can enhance patient safety and the quality of care for patients with depression.