Suicidality related to first-time admissions to psychiatric hospital

Incidence rate of suicidal behavior stratified by diagnosis among high-risk patients

BACKGROUND

Psychiatric diagnoses are known to increase suicide risk, but whether this risk varies across specific disorders remains unclear. Previous studies have often relied on retrospective designs or population-based databases, limiting comparability due to heterogeneous methodologies and follow-up periods.

AIMS

This study aimed to compare the incidence rates of unfavorable events (suicide or suicide attempts) among high-risk patients with Major Depressive Disorder (MDD), Bipolar Disorder (BD), and Schizophrenia over a 24-month follow-up period.

METHODS

This secondary analysis was conducted as part of a multicenter prospective cohort study involving 324 patients admitted to emergency departments for suicidal ideation or a recent suicide attempt. Clinical evaluations were performed at baseline and every six months to assess for unfavorable events. Additionally, Kaplan-Meier curves were estimated for each diagnosis, and Cox regression models were used to evaluate whether the diagnosis is associated with unfavorable events, adjusted for covariates such as age, history of childhood sexual abuse, and number of previous suicide attempts.

RESULTS

The incidence rates of suicide attempts were 27,000, 20,400, and 21,100 per 100,000 person-years for patients with MDD, BD, and Schizophrenia, respectively, while suicide rates were 1,600 per 100,000 person-years across all groups. No statistically significant differences were found in the risk of unfavorable events among diagnostic groups (p = 0.653), as confirmed by Kaplan-Meier survival analysis and Cox regression models.

CONCLUSIONS

Over a 2-year follow-up, psychiatric diagnosis alone did not predict significant differences in unfavorable events rates. Comprehensive suicide risk assessments should prioritize individual risk profiles over diagnostic categories. These findings underscore the importance of integrating biopsychosocial factors in suicide prevention strategies for high-risk psychiatric populations.

Study protocol for an adaptive, multi-arm, multi-stage (MAMS) randomised controlled trial of brief remotely delivered psychosocial interventions for people with serious mental health problems who have experienced a recent suicidal crisis: Remote Approaches to Psychosocial Intervention Delivery (RAPID)

BACKGROUND

People with serious mental health problems (SMHP) are more likely to be admitted to psychiatric hospital following contact with crisis services. Admissions can have significant personal costs, be traumatic and are the most expensive form of mental health care. There is an urgent need for treatments to reduce suicidal thoughts and behaviours and reduce avoidable psychiatric admissions.

METHODS

A multi-stage, multi-arm (MAMS) randomised controlled trial (RCT) with four arms conducted over two stages to determine the clinical and cost effectiveness of three psychosocial treatments, compared to treatment as usual (TAU), for people with SMHP who have had recent suicidal crisis. Primary outcome is any psychiatric hospital admissions over a 6-month period. We will assess the impact on suicidal thoughts and behaviour, hope, recovery, anxiety and depression. The remote treatments delivered over 3 months are structured peer support (PREVAIL); a safety planning approach (SAFETEL) delivered by assistant psychologists; and a CBT-based suicide prevention app accessed via a smartphone (BrighterSide). Recruitment is at five UK sites. Stage 1 includes an internal pilot with a priori progression criteria. In stage 1, the randomisation ratio was 1:1:1:2 in favour of TAU. This has been amended to 2:2:3 in favour of TAU following an unplanned change to remove the BrighterSide arm following the release of efficacy data from an independent RCT. Randomisation is via an independent remote web-based randomisation system using randomly permuted blocks, stratified by site. An interim analysis will be performed using data from the first 385 participants from PREVAIL, SAFETEL and TAU with outcome data at 6 months. If one arm is dropped for lack of benefit in stage 2, the allocation ratio of future participants will be 1:1. The expected total sample size is 1064 participants (1118 inclusive of BrighterSide participants).

DISCUSSION

There is a need for evidence-based interventions to reduce psychiatric admissions, via reduction of suicidality. Our focus on remote delivery of established brief psychosocial interventions, utilisation of different modalities of delivery that can provide sustainable and scalable solutions, which are also suitable for a pandemic or national crisis context, will significantly advance treatment options.

TRIAL REGISTRATION

ISRCTN33079589. Registered on June 20, 2022.

Suicidal ideation in patients with mental illness and concurrent substance use: analyses of national census data in Norway

BACKGROUND

Suicidal ideation may signal potential risk for future suicidal behaviors and death. We examined the prevalence of recent suicidal ideation in patients with mental illness and concurrent substance use and explored the clinical and sociodemographic factors associated with suicidal ideation in this patient subgroup, which represents a particular risk group for adverse psychiatric outcomes.

METHODS

We used national cross-sectional census data in Norway collected from 25,525 patients in specialized mental health services. The analytic sample comprised 3,842 patients with concurrent substance use, defined as having a co-morbid substance use disorder or who reported recent regular alcohol use/occasional illicit drug use. Data included suicidal ideation measured in relation to the current treatment episode, sociodemographic characteristics and ICD-10 diagnoses. Bivariate and multivariate analyses were used to examine differential characteristics between patients with and without suicidal ideation.

RESULTS

The prevalence of suicidal ideation was 25.8%. The suicidal ideation rates were particularly high for those with personality disorders, posttraumatic stress disorder, and depression, and for alcohol and sedatives compared with other substances. Patients with suicidal ideation were characterized by being younger, having single marital status, and having poorly perceived social relationships with family and friends.

CONCLUSION

Suicidal ideation in patients with mental illness and concurrent substance use was associated with a number of distinct characteristics. These results might help contribute to an increased focus on a subgroup of individuals at particular risk for suicidality and support suicide prevention efforts in specialized mental health services.

Associations between depressive symptom clusters and care utilization and costs among community-dwelling older adults

OBJECTIVES

Whether and how symptom clusters are associated with care utilization remains understudied. This study aims to investigate the economic impact of symptom clusters.

METHODS

We conducted cross-sectional analyses of data collected from 3255 older adults aged 60 years and over in Hong Kong using the Patient Health Questionnaire-9 and the Client Service Receipt Inventory to measure depressive symptoms and service utilization to calculate 1-year care expenditure. Based on Research Domain Criteria framework, we categorized depressive symptoms into four clusters: Negative Valance Systems and Externalizing (NVSE; anhedonia and depression), Negative Valance Systems and Internalizing (guilt and self-harm), Arousal and Regulatory Systems (sleep, fatigue, and appetite), and Cognitive and Sensorimotor Systems (CSS; concentration and psychomotor). Two-part models were used with four symptom clusters to estimate economic impacts on care utilization.

RESULTS

Core affective symptoms had the largest economic impact on non-psychiatric care expenditure; a one-point increase in NVSE was associated with USD$ 571 additional non-psychiatric care expenditure. The economic impacts of CSS on non-psychiatric care expenditure was attenuated when the severity level of NVSE was higher.

CONCLUSIONS

Our findings highlight the importance of understanding economic impacts on care utilization based on symptom profiles with a particular emphasis on symptom combinations. Policymakers should optimize care allocation based on older adults' depressive symptom profiles rather than simply considering their depression sum-score or the severity defined by cut-off points.

Association of depressive symptoms with health care utilization in older adults: Longitudinal evidence from the Survey of Health, Aging, and Retirement in Europe

OBJECTIVES

Many older adults with depression do not receive adequate treatment. Differences in treatment utilization may reflect the heterogeneous nature of depression, encompassing multiple distinct symptoms. We assessed whether depressive symptoms are differentially associated with subsequent health care utilization with respect to three outcomes as follows: (1) contact with a medical doctor (MD), (2) depression-specific treatment, and (3) inpatient psychiatric admission.

METHODS/DESIGN

Longitudinal analyses were based on data from three follow-up cycles conducted between 2004 and 2013 among 53,139 participants from the Survey of Health, Aging, and Retirement in Europe. Depressive symptoms were self-reported at baseline of each follow-up cycle using the 12-item EURO-D scale. Health care utilization was self-reported at the end of each follow-up cycle.

RESULTS

After adjustment for sex, age, country of interview, follow-up time, educational attainment, presence of a partner in household, body-mass index, the number of chronic diseases, disability, average/prior frequency of contact with an MD, and all other depressive symptoms, people with more frequent contact with an MD had most often reported sleep problems (IRR = 1.10) and fatigue (IRR = 1.10), followed by sad/depressed mood, tearfulness, concentration problems, guilt, irritability, and changes in appetite. Those treated for depression had most often reported sad/depressed mood (OR = 2.18) and suicidal ideation (OR = 1.72), but also sleep problems, changes in appetite, fatigue, concentration problems, hopelessness, and irritability. Sad/depressed mood (OR = 2.87) was also associated with psychiatric inpatient admission. Similarly to other outcomes, appetite change, fatigue, and sleep problems were associated with inpatient admission.

CONCLUSIONS

Specific symptoms of depression may determine utilization of different types of health care among elderly.

RD, Poindexter EK. Thwarted Interpersonal Needs and Suicide Ideation Distress Among Psychiatric Inpatients: The Moderating Role of Criminal Associates

Psychiatric inpatients are at elevated risk of suicide, and approximately half are criminal justice-involved. Their involvement with criminal associates may be linked to increased suicide ideation distress; however, this has not been examined. This study tested main effects of, and interactions between, thwarted belongingness (TB) or perceived burdensomeness (PB), time spent with associates, and associates' criminal involvement predicting suicide ideation distress. In our study, psychiatric inpatients (n = 139) completed assessments cross-sectionally. Results indicated that TB, PB, and associates' criminal involvement were significantly related to greater suicide ideation distress. A significant three-way interaction indicated participants who endorsed high TB, spent more time with associates, and had associates high in criminal involvement had the greatest probability of "Extreme" suicide ideation distress. These findings suggest that spending time with criminal associates may increase suicide ideation distress more than not having social interactions. Implications and limitations of this study are discussed.

Former suicidal inpatients' experiences of treatment and care in psychiatric wards in Norway

Purpose: The purpose of this study is to explore how former suicidal inpatients experienced treatment and care in psychiatric wards in Norway following the implementation of the National guidelines for prevention of suicide in mental health care. The focus of the analysis was on aspects of treatment and care with potential for improvement. Method: We interviewed five former inpatients and analysed the data by means of Interpretative Phenomenological Analysis. Results: Experiencing a sense of companionship with the staff and receiving individualized treatment and care was important for the participants. This involved establishing trusting connections with mental health workers who treated them with respect, made them feel valued, and who recognized their suffering and needs. The formerly suicidal patients experienced being in a recovery process, which was promoted by the support of mental health workers. Although the participants reported mostly positive experiences, there were examples of insufficient care. Sometimes, they felt that their suffering and suicidality were not sufficiently recognized. Conclusion: Our study indicates that although there has been increased focus on suicidality in the mental health services, among other through clinical guidelines, some mental health workers still lack competence and should focus more fully on how to provide individualized care for suicidal inpatients.

Do criminal associates impact psychiatric inpatients' social support and interpersonal needs?

Suicide risk is elevated among psychiatric inpatients; however, research has not examined moderators of the associations between perceived social support and thwarted belongingness (TB) and perceived burdensomeness (PB), such as involvement with criminal associates. Adult psychiatric inpatients (N = 142) completed assessments. Perceived social support was negatively associated with TB and PB; however, associates' criminal involvement did not moderate these associations. A significant interaction indicated a stronger negative association between perceived social support and TB when participants spent more time with associates. Therefore, time spent with associates, regardless of criminal involvement, may be a relevant interpersonal suicide risk factor.

Thwarted interpersonal needs mediate the relation between facets of mindfulness and suicide ideation among psychiatric inpatients

Previous research suggests a negative association between mindfulness and suicide ideation, yet limited research has examined the specific role of mindfulness on suicide ideation or attempted to link this construct with theory-driven risk factors for suicide among high-risk individuals. The current study examined the mediating role of thwarted interpersonal needs (i.e., thwarted belongingness and perceived burdensomeness) in the relation between facets of mindfulness and suicide ideation among psychiatric inpatients. Participants were 118 psychiatric inpatients who completed self-report assessments of mindfulness, thwarted belongingness, perceived burdensomeness, and suicide ideation. Results indicated that the additive effect of thwarted belongingness and perceived burdensomeness mediated the relation between the act with awareness, non-judging, and non-reactivity mindfulness facets, and suicide ideation. Facets of mindfulness appear to be differentially related to thwarted interpersonal needs and subsequent suicide ideation. Continued examination of specific facets of mindfulness, as they relate to suicide ideation, may highlight potentially important distinctions and better inform suicide risk assessment and treatment.

Association of comorbidity of mood and anxiety disorders with suicidal behaviors

BACKGROUND

Suicidal behaviors are strong predictors of suicide death and are much more common than completed suicides. This study aimed to describe the prevalence and transitions of suicidal behaviors in an Inner Mongolian City of China and to explore the association of comorbidity of mood and anxiety disorders with suicidal behaviors.

METHOD

This study was a cross-sectional study. The Composite International Diagnostic Interview-3.0 (CIDI-3.0) was administered face-to-face to make diagnoses of mental disorders, measure suicidal behaviors and collect social demographic information.

RESULTS

A total of 4528 respondents were interviewed. The lifetime prevalence of suicidal ideation, suicide plan and suicide attempt were 1.52%, 0.70% and 0.54%, respectively. Among those respondents with suicidal ideation, 21.1% of them had planned suicide attempt, and 6.6% had unplanned suicide attempt. When comorbidity was not considered in the model, mood and anxiety disorders were the most important drivers of suicidal behaviors. However, when including the comorbidity, those respondents with mood and anxiety disorders, rather than those with a specific disorder only, had a significant positive association with suicidal behaviors. In the model, being unemployed, rural, female, no income and childhood adversities were also related to suicidal behaviors.

LIMITATIONS

There might be systematic recall bias as the data were based on retrospective self-reports. Suicide is a sensitive question, so the respondents were probably ashamed to talk about suicidal behaviors.

CONCLUSIONS

The comorbidity of mood and anxiety disorders was the most important risk factor of suicidal behaviors. Special attention should be paid to those patients with this comorbidity.

Suicide Attempts and Personal Need for Structure Among Ex-Offenders

Suicide attempts were examined in relation to sociodemographic (age, gender, ethnicity), psychopathological (prior psychiatric hospitalizations, physical and sexual abuse histories), and cognitive (personal need for structure) variables among a sample of ex-offenders with substance use disorders ( N = 270). Hierarchical logistic regression was conducted to determine whether personal need for structure would significantly predict whether participants reported past suicide attempts beyond sociodemographic and psychopathological predictors. Personal need for structure and prior psychiatric hospitalizations were the only significant predictors, with higher values of these predictors increasing the likelihood of suicide attempts. Findings are consistent with a cognitive model for understanding suicide behavior, suggesting that persons with a high need for cognitive structures operate with persistent and rigid thought processes that contribute to their risk of suicide.

Prevalence and characteristics of suicide attempters and ideators among acutely admitted psychiatric hospital patients in northwest Russia and northern Norway

BACKGROUND

More knowledge about suicidality and suicide risk profiles in acute psychiatric hospital patients (both first-time and chronic patients) is needed. While numerous factors are associated with suicidality in such populations, these may differ across cultures. Better understanding of factors underlying suicide risk can be informed by cross-cultural studies, and can aid development of therapeutic and preventive measures.

METHODS

An explorative, cross-sectional cohort study was carried out. Acutely admitted patients at one psychiatric hospital in northwest Russia and two in northern Norway were included. At admission, demographic, clinical, and service use data were collected, in addition to an assessment of suicidal ideation and attempts, comprising five dichotomic questions. Data from 358 Norwegian and 465 Russian patients were analyzed with univariate and multivariate statistics. Within each cohort, attempters and ideators were compared with patients not reporting any suicidality.

RESULTS

The observed prevalence of suicidal ideation and attempts was significantly higher in the Norwegian cohort than in the Russian cohort (χ(2) = 168.1, p < 0,001). Norwegian suicidal ideators and attempters had more depressed moods, more personality disorders, and greater problems with alcohol/drugs, but fewer psychotic disorders, cognitive problems or overactivity than non-suicidal patients. Russian suicidal ideators and attempters were younger, more often unemployed, had more depressed mood and adjustment disorders, but had fewer psychotic disorders and less alcohol/drug use than the non-suicidal patients.

CONCLUSIONS

Rates of suicidal ideation and non-fatal attempts in Norwegian patients were intermediate between those previously reported for patients admitted for the first time and those typical of chronic patients. However, the significantly lower rates of suicidal ideation and non-fatal attempts in our Russian cohort as compared with the Norwegian, contrasted with what might be expected in a region with much higher suicide rates than in northern Norway. We suggest that suicide-related stigma in Russia may reduce both patient reporting and clinicians' recognition of suicidality. In both cohorts, overlapping risk profiles of ideators and attempters may indicate that ideators should be carefully evaluated and monitored, particularly those with depressed moods, alcohol/substance abuse disorders, and inadequate treatment continuity.

Psychiatric consultations and therapy recommendations following a suicide attempt in a general hospital and their associations with selected parameters in a 1-year period

OBJECTIVE

Our study aims to determine the frequency and distribution of suicide attempts according to the patients' characteristics and type of suicide attempt as well as the method of treatment proposed by the consultation-liaison service in a general hospital.

METHODS

This retrospective naturalistic study covers a 1-year period (2012), during which 51 suicide attempters were hospitalised in the Charité Berlin, Campus Benjamin Franklin, Germany. The following data were analysed: method of suicide, account of prior psychiatric history and medication, as well as the acute psychiatric diagnosis and treatment - including pharmacotherapy.

RESULTS

Most of the patients were diagnosed with a psychiatric illness. Major depressive disorder was the most frequent diagnosis in consultation. Treatment recommendations more often entailed further psychiatric treatment than medication. In the cases where medication was indeed given, benzodiazepines were the most frequently prescribed.

CONCLUSIONS

Most of the suicide attempters needed further therapy in psychiatric hospitals. A specialised pharmacotherapy (antidepressants, mood stabilisers) was rarely recommended by the psychiatric consultation service. The psychiatric consultation and therapy recommendations are important in guiding future acute treatment procedures.

Patterns of referral in first-episode schizophrenia and ultra high-risk individuals: results from an early intervention program in Italy

PURPOSE

This study set out to investigate the patterns of referral in a sample (n = 206) of patients having first-time access to an Italian comprehensive program that targets the early detection of and early intervention on subjects at the onset of psychosis. The primary goal of the study was to investigate the duration of untreated illness (DUI) and/or the duration of untreated psychosis (DUP) in the sample since the implementation of the program.

METHOD

Data on pathways of referrals prospectively collected over a 11-year period, from 1999 to 2010; data referred to patients from a defined catchment area, and who met ICD-10 criteria for a first episode of a psychotic disorder (FEP) or were classified to be at ultra-high risk of psychosis (UHR) according to the criteria developed by the Personal Assessment and Crisis Evaluation (PACE) Clinic in Melbourne. Changes over time in the DUI and DUP were investigated in the sample.

RESULTS

Referrals increased over time, with 20 subjects enrolled per year in the latter years of the study. A large majority of patients contacted a public or private mental health care professional along their pathway to treatment, occurring more often in FEP than in UHR patients. FEP patients who had contact with a non-psychiatric health care professional had a longer DUP. Over time, DUP and DUI did not change in FEP patients, but DUI increased, on average, in UHR patients.

CONCLUSIONS

The establishment of an EIP in a large metropolitan area led to an increase of referrals from people and agencies that are not directly involved in the mental health care system; over time, there was an increase in the number of patients with longer DUI and DUP than those who normally apply for psychiatric services.

Sex differences in mortality of admitted patients with personality disorders in North Norway--a prospective register study

BACKGROUND

It is well established that patients with serious mental disorders have higher mortality than the general population, yet there are few studies on mortality of both natural and unnatural causes in patients with personality disorders. The aim of this study was to investigate the mortality of in-patients with personality disorder diagnosis in a 27-year follow-up cohort in North Norway, with a special focus on gender differences.

METHOD

Based on a hospital case register covering 1980 to 2006, 284 female and 289 male patients were included. The cohort was linked to the Norwegian Cause of Death Registry for information concerning mortality. The mortality rates were adjusted for age by applying a Poisson regression model. The relative mortality in men compared to women was tested with Cox regression with attained age as the time variable. The number of deaths to be expected among the patients if the mortality rates of the general population in Norway had prevailed was estimated and excess mortality, expressed by the standardized mortality ratio (SMR), calculated.

RESULTS

When compared to the mortality in the general population, men and women with personality disorder diagnoses had 4.3 (95% CI: 3.2-5.9) and 2.9 (95% CI: 1.9-4.5) times, respectively, increased total mortality. Patients with personality disorder diagnoses have particularly high mortality for unnatural deaths; 9.7 (95% confidence interval (CI): 6.3-15.1) times higher for men and 17.8 (95% CI: 10.1-30.3) for women, respectively, and even higher for suicides--15 (95% CI: 9-27) for men and 38 (95% CI: 20-70) for women. The mortality due to natural causes was not statistically significantly increased in women, whereas men had 2.8 (95% CI: 1.8-4.4) times higher mortality of natural deaths than the general population.

CONCLUSION

Compared to the general population, patients with a personality disorder have high mortality, particularly mortality from unnatural causes. The number of deaths caused by suicides is especially high for women. Men also have higher mortality of natural causes than the general population.

Acknowledging illness and treatment needs in first-time admitted psychiatric patients

PURPOSE

Help-seeking and service utilization depends on the patients' interpretation of their illness and treatment needs. Worry, denial of illness, need for treatment and need for hospitalization in first-time admitted patients was studied.

SUBJECTS

New patients in two mental hospitals were consecutively recruited. Three hundred and thirty-four satisfied the inclusion criteria and 251 gave informed consent. One hundred and ninety-six had complete datasets (56% of those eligible).

METHODS

Demography was recorded with the Minimal Basic Dataset by Ruud et al. (1993). Experiences of hospitalisation were measured with the Patient's Experience of Hospitalisation Questionnaire by Carskey et al. (1992). MINI was used for diagnosing and SCL-90-R by Derogatis (1997) for subjective symptoms. Standard multiple regressions were performed with the PEH subscales (Denial, Worry, Need for treatment and Need for hospitalisation) as dependents and demography, diagnosis and SCL-90-R subscales as explanatory variables.

RESULTS

(a) Psychoticism and the diagnosis of schizophrenia were associated with little worrying, denial of illness, of treatment needs and of need for hospitalisation. (b) Anxiety and affective disorders were related to worries, acknowledgement of illness, need for treatment and for hospitalisation.

CONCLUSIONS

In contrast to patients with mainly anxiety and affective disorders, psychotic patient tended to deny illness-related worries, that they had an illness and that they needed treatment and hospitalisation. An affective disorder together with suicidal thoughts (not attempts) was a strong drive towards hospital admission.