patients used medication at appropriate doses, leading the authors to conclude that overall quality of care was moderate to low. Two findings of the study are particularly relevant to suicide prevention: (1) patients with suicidal ideation did not receive higher rates of treatment than did patients without suicidal ideation (using measures of process and quality); (2) patients with both depression and alcohol abuse—which places them at higher risk of suicide—were not given more specialty referrals, as recommended by treatment guidelines (see later section on Substance Abuse). While the study did not assess outcomes of care, it did conclude that patients with suicidal ideation and other “silent,” yet serious, symptoms are at particular risk for not receiving appropriate treatment by managed care organizations. Another study, of serious suicide attempters in Florida, found that managed care’s criteria for approving admission to hospitals were not predictive of features seen in patients who made such attempts (Hall et al., 1999).

A largely unstudied question is whether reductions in intensity of outpatient services, or in length of stay in inpatient care, contribute to suicide risk. A case-control study of completed suicides in the UK found that “reduction in care” at the final service contact was associated with almost a 4-fold increase in risk of suicide (Appleby et al., 1999). Reduction in care was defined by the study as one or more of the following: reduced appointment frequency, lowered doses of medication, less supervised location (e.g., transfer from day hospital or outpatient), or discharge from follow-up. While this study was not of managed care per se, it raises questions about cost containment strategies used by managed care to reduce intensity or frequency of services for people at risk of suicide. In related findings, initial results from a study of all hospital discharges in Pennsylvania found a 25 percent reduction in length of stay during a 3-year period for inpatient treatment of depression. Preliminary results suggest that the reduction in length of stay was accompanied by an increase in readmission rates, a finding that the study investigators interpreted as suggesting that caution should be used when implementing practice guidelines for length of stay (personal communication, J. Harman, University of Pittsburgh School of Medicine, December 18, 2001).

Given the concerns about quality of care and lack of monitoring by managed care, the Surgeon General’s National Strategy for Suicide Prevention (PHS, 2001) explicitly recommends implementation of quality care/ utilization management guidelines by managed care organizations and health insurance plans for effective response to, and treatment of, individuals at risk for suicide. Quality improvement guidelines have been demonstrated to be successful at improving productivity and outcomes of depression in managed care, according to a randomized controlled trial (Wells et al., 2000).

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