The aim of this study was to investigate whether increased mental health services resources had an impact on suicide mortality in the five Norwegian health regions in the period 1990-2006. Although substantial changes in mental health services resources were observed (Table 1), suicide mortality in both females and males was statistically unrelated to these changes (adjusted p > 0.05) (Tables 3 and 4).
Despite the observed decline in hospital beds, the number of discharges increased by 113% during the study period; this apparent discrepancy can be explained by the decline in the average length of hospital stays . The additional increase in outpatient consultations and man-labour years by all personnel indicates that more patients were treated throughout the period. It can be argued that the shortened length of stays increases the risk of incomplete recovery, and may thereby explain the excess suicide risk generally observed in the immediate post-discharge period . However, the data in the present study did not indicate increased suicide risk due to reduction in inpatient days.
Several of the adjustment variables were significantly associated with suicide mortality. Among females, increased sales of antidepressants were associated with a decline in suicide mortality (adjusted p = 0.03), while increased sales of alcohol were associated with an increase in suicide mortality (adjusted p = 0.01). Among males, increased level of college and university education were associated with a decline in suicide mortality (adjusted p = 0.01), while reduction of unemployment was associated with a decline in suicide mortality (adjusted p = 0.01). Crude differences in male and female suicide mortality were observed across the health regions. Among females, these differences do not change in the adjusted analysis; however, adjustments for educational level and the level of unemployment impact the regional differences among males. We do not know why these crude regional differences in female and male suicide mortality exist.
The present study should be interpreted with caution, because statistical associations can be masked by the fact that we may have failed to adjust for relevant confounders. Another shortcoming in the present study is that we only had one variable that directly measured the increased resources in outpatient services. Due to the process of downsizing traditional psychiatric hospitals, present mental health services policy favours active outpatient treatment. Therefore, the negative findings may be due to restricted measurements on outpatient mental health services. Further, the increased resources in child and adolescent mental health services, which were not addressed in this study, may pay off in lower suicide rates later on. Finally, it is important to be aware that associations at the individual level cannot be deduced from an ecological study design.
Our findings are in line with a recently published, cross-national, ecological study that revealed no relation between suicide rates and mental health funding, service provision, or national policies on mental health . Further, in an ecological study from the United Kingdom, Lewis and co-workers  examined the association between standardised suicide mortality ratios and the provision of mental health services. The results demonstrated that higher quantity of provision was not negatively associated with standardised suicide mortality ratios. In addition, our findings are in line with a prospective, multi-level study from the United States, in which the researcher found no association between variation in patterns of service delivery at the system level and suicide risk . However, there are ecological studies that have reported associations between various measurements of mental health services provision and suicide rates [16, 20, 21]. For example, Kapusta  and co-workers found that both sales of antidepressants and density of psychotherapists were negatively associated with suicide rates.
It is undisputable that the Norwegian mental health services have been strengthened in quantitative terms. However, little is known about the content of the treatment given and therefore the quality and effectiveness of the treatment . Hence, we do not know whether more patients were successfully treated during this period. In addition, varied, interdisciplinary outpatient services that are specialised in handling suicidal patients have not been developed.
Far from all suicidal mental health patients are receiving treatments that have proven to have a preventive effect on suicide. A recent health technology assessment (review of the literature) of the effects of mental health services interventions for the prevention of suicide found that few interventions were specifically tailored to reduce suicidality . Most of the studies examined in the assessment evaluated the effect of treatment related to mental illness per se. Further: "the inclusion and exclusion criteria were not always well described and in a number of studies individuals with high suicide risk were not included" . This strategy, according to which suicidality is conceptualised as a symptom of mental illness and prevention of suicide requires treatment of the underlying disease, has come under increasing criticism [14, 39, 40]. An alternative strategy has been proposed, namely, a focus on suicidality as the primary clinical target, in which suicidal behaviour and its causes are addressed directly [14, 39]. In this approach, the individual is seen as primarily suicidal with various sub-symptoms of mental illness in need of treatment .
Because suicide is a multi-factorial phenomenon, it is also reasonable to infer that effective suicide prevention strategies must be broader than the focus on the treatment of mental disorders. For example, public health prevention strategies that have aimed at restricting suicide means [41–43], toning down media reports , and restricting alcohol  have been demonstrably successful. Multidisciplinary approaches to suicide research and prevention are needed, which require research teams with "a balanced composition between biologically and psychologically oriented investigators" , and there is a "need to evaluate also other concomitant factors such as socio-economic, cultural, and religious aspects" .
A multidisciplinary approach does not preclude the priority of suicide prevention among psychiatric patients, who constitute a group at increased risk; however, treatment ought to target suicidality more specifically.