A multilevel analysis of mental health service utilization by individuals bereaved by suicide in Norway: examining the impact of system-level factors

PURPOSE: Suicide bereavement is linked to increased risk of mental health problems and suicide. While individual-level determinants of service use have been identified, system-level factors, e.g., service capacity and accessibility, remain underexplored. We aimed to investigate whether system-level factors were associated with mental health service utilisation among suicide-bereaved individuals in Norway. METHODS: We analysed data on 14,628 individuals (aged 20-70) bereaved by suicide during 2010-2019, using four previously identified service utilisation trajectories. Among the bereaved, 54% had low service utilisation pre- and post-bereavement and 30% only attended their General Practitioner (GP) post-bereavement for mental health reasons. Small groups of bereaved had a marked increase of mental health service use immediately post-bereavement (9%) or had persistently high utilisation (7%). Health service use was assessed through nationwide linked registers at individual, municipality, and District Psychiatric Centres (DPC) levels using a retrospective observational cohort design. Five system-level factors were examined with multilevel multinomial logistic regression, adjusting for individual characteristics. RESULTS: Those who lived in larger municipalities had higher service use. Longer travel times to DPCs were associated with lower specialist utilisation. In municipalities with generally high GP utilisation, bereaved were more likely to consult GPs only, while those who lived in DPC districts with high outpatient rates were more likely to consult mental health specialists post-bereavement. CONCLUSIONS: Healthcare-related system-level characteristics were associated with patterns of mental health service utilisation among suicide-bereaved individuals. Urban environments and higher service availability predicted increased utilisation, but geographic barriers persist. Postvention strategies might include efforts to improve accessibility.