Suicide among psychiatric patients: a case-control study

The Role of Socioeconomic Position in the Association Between Mental Disorders and Mortality: A Systematic Review and Meta-Analysis

Importance

Studies are lacking summarizing how the association between mental disorders and mortality varies by socioeconomic position (SEP), particularly considering different aspects of SEP, specific types of mental disorders, and causes of death.

Objective

To investigate the role of SEP in the association between mental disorders and mortality and the association between SEP and mortality among people with mental disorders.

Data Sources

MEDLINE, Embase, PsycINFO, and Web of Science were searched from January 1, 1980, through April 3, 2023, and a snowball search of reference and citation lists was conducted.

Study Selection

Inclusion criteria were observational studies estimating the associations between different types of mental disorders and mortality, stratified by SEP and between SEP and mortality in people with mental disorders.

Data Extraction and Synthesis

Pairs of reviewers independently extracted data using a predefined data extraction form and assessed the risk of bias using the adapted Newcastle-Ottawa scale. Graphical analyses of the dose-response associations and random-effects meta-analyses were performed. Heterogeneity was explored through meta-regressions and sensitivity analyses.

Main Outcomes and Measures

All-cause and cause-specific mortality.

Results

Of 28 274 articles screened, 71 including more than 4 million people with mental disorders met the inclusion criteria (most of which were conducted in high-income countries). The relative associations between mental disorders and mortality were similar across SEP levels. Among people with mental disorders, belonging to the highest rather than the lowest SEP group was associated with lower all-cause mortality (pooled relative risk [RR], 0.79; 95% CI, 0.73-0.86) and mortality from natural causes (RR, 0.73; 95% CI, 0.62-0.85) and higher mortality from external causes (RR, 1.18; 95% CI, 0.99-1.41). Heterogeneity was high (I2 = 83% to 99%). Results from subgroup, sensitivity, and meta-regression analyses were consistent with those from the main analyses. Evidence on absolute scales, specific diagnoses, and specific causes of death was scarce.

Conclusion and Relevance

This study did not find a sufficient body of evidence that SEP moderated the relative association between mental disorders and mortality, but the underlying mortality rates may differ by SEP group, despite having scarcely been reported. This information gap, together with our findings related to SEP and a possible differential risk between natural and external causes of death in individuals with specific types of mental disorders, warrants further research.

Suicide among those who use mental health services: Suicide risk factors as evidenced from contact-based characteristics in Victoria

OBJECTIVE

The majority of suicide decedents have had contact with health services in the months before their death. Contacts for mental health services present potential suicide prevention opportunities. This study aims to compare contact-based characteristics among suicide decedents and living controls in the year subsequent to clinical mental health contact with the public health system in Victoria, Australia.

METHODS

A population-based nested case-control study of those who had mental health-related hospital and community contacts with the public health system was conducted. Cases (suicide decedents) were age and gender-matched to living controls (suicide non-decedents). These records were linked to records of suicides that occurred in the 12 months following the health service contact, between January 1, 2011, and December 31, 2016. Victorian residents aged 10 years and above were selected at the time of contact (483,933 clients). In the study population, conditional logistic regression models were used to assess the relationship between contact-based characteristics and suicide. Socio-demographics and mental health-related hospital and community contact data was retrieved from the Victorian Admitted Episodes Dataset, the Victorian Emergency Minimum Dataset and the Public Clinical Mental Health database and suicide data from the Victorian Suicide Register.

RESULTS

During a six-year period, 1,091 suicide decedents had at least one mental health contact with the public health system in the 12 months preceding the suicide. Overall, controls used more mental health services than cases; however, cases used more mental health services near the event. The relationship between the type of service and suicide differed by service type: hospital admissions and emergency department presentations had a significant positive association with suicide with an OR of 2.09 (95% CI 1.82-2.40) and OR of 1.13 (95% CI 1.05-1.22), and the effect size increased as the event approached, whereas community contacts had a significant negative association with an OR of 0.93 (95% CI 0.92-0.94), this negative association diminished in magnitude as the event approached (OR∼1).

CONCLUSION

Suicide decedents had less contact with mental health services than non-decedents; however, evidence suggests suicide decedents reach out to mental health services proximal to suicide. An increase in mental health service contact by an individual could be an indication of suicide risk and therefore an opportunity for intervention. Further, community level contact should be further explored as a possible prevention mechanism considering the majority of suicide decedents do not access the public clinical mental health services.

How health care systems let our patients down: a systematic review into suicide deaths

PURPOSE

To synthesize the literature in relation to findings of system errors through reviews of suicide deaths in the public mental health system.

DATA SOURCES

A systematic narrative meta-synthesis using the PRISMA methodology was conducted.

STUDY SELECTION

All English language articles published between 2000 and 2017 that reported on system errors identified through reviews of suicide deaths were included. Articles that reported on patient factors, contact with General Practitioners or individual cases were excluded.

DATA EXTRACTION

Results were extracted and summarized. An overarching coding framework was developed inductively. This coding framework was reapplied to the full data set.

RESULTS OF DATA SYNTHESIS

Fourteen peer reviewed publications were identified. Nine focussed on suicide deaths that occurred in hospital or psychiatric inpatient units. Five studies focussed on suicide deaths while being treated in the community. Vulnerabilities were identified throughout the patient's journey (i.e. point of entry, transitioning between teams, and point of exit with the service) and centred on information gathering (i.e. inadequate and incomplete risk assessments or lack of family involvement) and information flow (i.e. transitions between different teams). Beyond enhancing policy, guidelines, documentation and regular training for frontline staff there were very limited suggestions as to how systems can make it easier for staff to support their patients.

CONCLUSIONS

There are currently limited studies that have investigated learnings and recommendations. Identifying critical vulnerabilities in systems and to be proactive about these could be one way to develop a highly reliable mental health care system.

The case for case-control studies in the field of suicide prevention

Much of our knowledge about the risk factors for suicide comes from case-control studies that either use a psychological autopsy approach or are nested within large register-based cohort studies. We would argue that case-control studies are appropriate in the context of a rare outcome like suicide, but there are issues with using this design. Some of these issues are common in psychological autopsy studies and relate to the selection of controls (e.g. selection bias caused by the use of controls who have died by other causes, rather than live controls) and the reliance on interviewing informants (e.g. recall bias caused by the loved ones of cases having thought about the events leading up to the suicide in considerable detail). Register-based studies can overcome some of these problems because they draw upon contain information that is routinely collected for administrative purposes and gathered in the same way for cases and controls. However, they face issues that mean that psychological autopsy studies will still sometimes be the study design of choice for investigating risk factors for suicide. Some countries, particularly low and middle income countries, don't have sophisticated population-based registers. Even where they do exist, there will be variable of interest that are not captured by them (e.g. acute stressful life events that may immediately precede a suicide death), or not captured in a comprehensive way (e.g. suicide attempts and mental illness that do not result in hospital admissions). Future studies of risk factors should be designed to progress knowledge in the field and overcome the problems with the existing studies, particularly those using a case-control design. The priority should be pinning down the risk factors that are amenable to modification or mitigation through interventions that can successfully be rolled out at scale.

The Attitude of Psychiatric and Non-psychiatric Health-care Workers Toward Suicide in Malaysian Hospitals and Its Implications for Training

OBJECTIVES

This research is aimed to examine the attitude of health-care workers toward suicidal patients in Malaysian hospitals, comparing responses from psychiatric and non-psychiatric workers, and to identify specific needs in suicide prevention and management training.

METHOD

This is a multi-site cross-sectional study. The authors conducted a survey based on a translated self-administered questionnaire to participants from seven core hospital departments.

RESULTS

While most health-care workers regardless of department and specialty took their duty to prevent suicide seriously, a large majority of them expressed negative attitudes such as finding suicidal behavior irritating, and more than half believed suicidal attempts were a way of making others sorry. However, psychiatric workers were less likely to have judgmental attitudes that included believing suicide attempters as being selfish or trying to get sympathy from others.

CONCLUSIONS

As there were more similarities than differences in health-care workers' attitudes toward suicide, recommendations on basic and continuous suicide prevention and management training among hospital workers were made. The interventions focused on improving knowledge, affective, and skill-based areas that were aimed to correct the wrongful understanding of and to minimize the negative attitudes toward suicidal individuals indicated by the study results.

Indo-Canadian Collaboration for Suicide Prevention: Training Needs Assessment for Healthcare Professionals in India

The main purpose of the study was to conduct a comprehensive needs assessment of primary healthcare professionals in order to develop a training program aimed at enhancing competencies in suicide risk assessment and management. A total of 144 primary healthcare professionals (physicians = 46; primary care workers = 98) completed the needs assessment questionnaire. The majority of healthcare professionals rated their level of comfort and competence in assessing, treating, and referring suicidal patients as medium or high. However, their knowledge about suicide, risk factors for suicide, asking about suicidal behaviour, and helping a suicidal patient was rated low or medium. Overall, the scarcity of qualified healthcare professionals and the existing gaps in core competencies for suicide risk assessment and management was identified. Development of innovative and effective competencies-based suicide specific training for primary care providers in India is urgently required.

Preventing suicide among inpatients

OBJECTIVE

Inpatient suicide comprises a proportionately small but clinically important fraction of suicide. This study is intended as a qualitative analysis of the comprehensive English literature, highlighting what is known and what can be done to prevent inpatient suicide.

METHOD

A systematic search was conducted on the Cochrane Library, PubMed, Embase, Web of Knowledge, and a personal database for articles on cohort series, preferably controlled, of inpatient suicide (not deliberate self-harm or attempted suicide, unless they also dealt specifically with suicide data).

RESULTS

A qualitative discussion is presented, based on the findings of the literature searched.

CONCLUSIONS

The bulk of inpatient suicides actually occur not on the ward but off premises, when the patient was on leave or had absconded. Peaks occur shortly after admission and discharge. It is possible to reduce suicide risk on the ward by having a safe environment, optimizing patient visibility, supervising patients appropriately, careful assessment, awareness of and respect for suicide risk, good teamwork and communication, and adequate clinical treatment.

Risk factors for suicide within a year of discharge from psychiatric hospital: a systematic meta-analysis

BACKGROUND

The increased risk of suicide in the period after discharge from a psychiatric hospital is a well-recognized and serious problem.

OBJECTIVE

The aim of this study was to establish the risk factors for suicide in the year after discharge from psychiatric hospitals and their usefulness in categorizing patients as high or low risk for suicide in the year following discharge.

METHOD

A systematic meta-analysis of controlled studies of suicide within a year of discharge from psychiatric hospitals.

RESULTS

There was a moderately strong association between both a history of self-harm (OR = 3.15) and depressive symptoms (OR = 2.70) and post-discharge suicide. Factors weakly associated with post-discharge suicide were reports of suicidal ideas (OR = 2.47), an unplanned discharge (OR = 2.44), recent social difficulty (OR = 2.23), a diagnosis of major depression (OR = 1.91) and male sex (OR = 1.58). Patients who had less contact with services after discharge were significantly less likely to commit suicide (OR = 0.69). High risk patients were more likely to commit suicide than other discharged patients, but the strength of this association was not much greater than the association with some individual risk factors (OR = 3.94, sensitivity = 0.40, specificity = 0.87).

CONCLUSIONS

No factor, or combination of factors, was strongly associated with suicide in the year after discharge. About 3% of patients categorized as being at high risk can be expected to commit suicide in the year after discharge. However, about 60% of the patients who commit suicide are likely to be categorized as low risk. Risk categorization is of no value in attempts to decrease the numbers of patients who will commit suicide after discharge.

Suicides in users of mental health care services: treatment characteristics and hindsight reflections

The current study aims to describe the patient and treatment characteristics of a sample of 505 suicides by mental health care patients, and to determine how clinicians view the care provided and what they learned. The results indicate that the quality of mental health care for suicidal patients could be improved by focusing on communication among clinicians, continuity of care, suicide risk assessment procedures, and the involvement of relatives.

Rural-urban differences in suicide rates for current patients of a public mental health service in Australia

Rural versus urban rates of suicide in current patients of a large area mental health service in Australia were compared. Suicide deaths were identified from compulsory root cause analyses of deaths, 2003-2007. Age-standardized rates of suicide were calculated for rural versus urban mental health service and compared using variance of age-standardized rates with 95% confidence intervals. There were 44 suicides and the majority (62%) were rural. Only urban patients used jumping from heights as a method of suicide (4/17; p = 0.02). Rural patients had 2.7 times higher rates of suicide, similar to findings for rural versus urban community suicides and may reflect the underlying community rates, differences in mental health service delivery, or socioeconomic disadvantage.

Suicide in recently discharged psychiatric patients: a case-control study

BACKGROUND

Few controlled studies have specifically investigated aspects of mental health care in relation to suicide risk among recently discharged psychiatric patients. We aimed to identify risk factors, including variation in healthcare received, for suicide within 3 months of discharge.

METHOD

We conducted a national population-based case-control study of 238 psychiatric patients dying by suicide within 3 months of hospital discharge, matched on date of discharge to 238 living controls.

RESULTS

Forty-three per cent of suicides occurred within a month of discharge, 47% of whom died before their first follow-up appointment. The first week and the first day after discharge were particular high-risk periods. Risk factors for suicide included a history of self-harm, a primary diagnosis of affective disorder, recent last contact with services and expressing clinical symptoms at last contact with staff. Suicide cases were more likely to have initiated their own discharge and to have missed their last appointment with services. Patients who were detained for compulsory treatment at last admission, or who were subject to enhanced levels of aftercare, were less likely to die by suicide.

CONCLUSIONS

The weeks after discharge from psychiatric care represent a critical period for suicide risk. Measures that could reduce risk include intensive and early community follow-up. Assessment of risk should include established risk factors as well as current mental state and there should be clear follow-up procedures for those who have self-discharged. Recent detention under the Mental Health Act and current use of enhanced levels of aftercare may be protective.

Suicide in psychiatric patients: case-control study in Singapore

OBJECTIVE

Persons with psychiatric illness, especially depression and schizophrenia, are at relatively high risk of suicide, but there are few studies that look at the Asian population. The aim of the present study was to identify the risk period and risk factors for suicide in psychiatric patients in Singapore. The nature of psychiatric care that was provided, both inpatient and outpatient, was also explored.

METHOD

This is a case-control study of 123 patients who committed suicide from 2003 to 2004. Controls were 123 surviving patients who were individually matched for age, gender, principal diagnosis and calendar time.

RESULTS

The most common principal diagnoses among the suicide subjects were schizophrenia (46.3%) and depression (26.8%). Numerous factors were associated with significantly increased suicide risk. Stepwise conditional logistic regression showed that the following three independent factors best predicted suicide: history of attempted suicide using highly lethal means; coexisting significant physical illness; and delusions. Suicides occur mainly soon after discharge and after an outpatient consult. Subgroup analyses were done to distinguish between subjects who suicided early and late following discharge.

CONCLUSIONS

Suicidal risk remains high in Singaporean psychiatric patients soon after discharge. They share some common risk factors for suicide identified in Western studies but the lower prevalence of substance abuse and comorbidity in Singaporean suicide subjects was one notable difference. The phenomena of suicides soon after discharge and outpatient review suggest the need for proper identification and more intensive follow up during this period.

Impact of a specialized early psychosis treatment programme on suicide. Retrospective cohort study

BACKGROUND

Younger people, early in the course of psychotic illness, are at high risk of suicide.

AIM

To investigate the impact of a specialized early psychosis (EP) treatment programme on risk of suicide up to 8.5 years following first contact with mental health services.

METHODS

A population-based, retrospective cohort study of 7760 individuals with a psychotic disorder, aged 15-29 years at first contact, ascertained from a statewide psychiatric case register. Suicides were identified by linking the psychiatric register to a coronial register of unnatural deaths. Cox proportional hazards models were used to investigate potential risk factors, including specialized EP treatment, for suicide.

RESULTS

Our principal hypothesis, that suicide risk over the entire follow-up period would be significantly lower for those who received specialized EP treatment compared with those who did not, was not supported. However, a secondary analysis found that, after adjusting for other socio-demographic, clinical and treatment factors, suicide risk was 50% lower in the first 3 years following first contact with mental health services among those exposed to specialized EP treatment compared with those who were not. History of inpatient treatment, more treatment days per annum, and shorter time to establish a psychotic diagnosis were associated with increased risk. Non-participation in the labour force or in study, compared with being unemployed, exerted a protective effect.

CONCLUSIONS

The EP treatment model may afford protection from suicide whilst the EP intervention is delivered and for a limited period afterwards.

The characteristics of suicides within a week of discharge after psychiatric hospitalisation - a nationwide register study

BACKGROUND

The characteristics of victims of immediate post-discharge suicides are not well known. We explored these characteristics for the purposes of better recognition and preventive efforts of potential immediate post-discharge suicides.

METHODS

Suicides from a Finnish nationwide register were linked with preceding periods of psychiatric inpatient treatment. Characteristics of suicides within a week of discharge were compared to those occurring later after discharge.

RESULTS

Compared to other previously hospitalised suicide victims, those committing suicide within a week of discharge were more often female, unmarried, had a higher grade of education and a diagnosis of schizophrenia spectrum or affective disorder, tended to use more drowning and jumping from heights as the methods for suicide and had gained a smaller improvement in psychological functioning during hospitalization.

CONCLUSION

These characteristics indicate a more severe psychopathology, relatively poorer level of functioning, less global response to hospitalisation, and a more frequent choice of lethal and easily available method for suicide. Potentially suicidal psychiatric patients should be better recognized and an immediate follow-up arranged if it is decided they be discharged.

Long- and Short-Term Risk Factors in the Prediction of Inpatient Suicide

Abstract. The prediction of suicide remains a major challenge for health care professionals in inpatient settings. A clearer identification of factors specific to inpatient suicide is required to improve both practice and research within this area. This paper provides an overview of the inpatient suicide literature to date focusing on two particularly salient themes: Long term and short term prediction of suicide. Since the concept of short-term suicide risk dominates clinical practice, issues in relation to dynamic risk factors are emphasized.

Suicide after discharge from psychiatric inpatient care: a case-control study in Hong Kong

OBJECTIVE

To identify the risk period and the risk factors for suicide in Chinese psychiatric patients after discharge from inpatient psychiatric treatment. The nature of psychiatric aftercare provided to these patients was also explored.

METHOD

A case control study with 73 patients who were discharged from a large psychiatric unit in Hong Kong between January 1996 and December 1999 and had received coroners' verdict of suicide or undetermined death within the same period. Controls were 73 surviving patients discharged from the same unit. They were individually matched for sex, age, psychiatric diagnosis, and date of discharge.

RESULTS

Post-discharge clustering of suicides was observed among the cases. Nearly 80% of them died within 1 year of discharge. The most common principal diagnosis among the cases was schizophrenia and related psychotic disorders. Multivariate analysis showed that suicide was associated with: unemployment (OR = 12.2, 95% CI = 2.1 - 70.4), past suicidal attempts (OR = 3.4, 95% CI = 1.2 - 9.6), maternal mental illness (OR = 13.4, 95% CI = 1.0 - 170.0), and suicidal ideation or attempt before the last admission (OR = 5.0, 95% CI = 1.4 - 18.0). The psychiatric aftercare received by cases and controls were generally similar. However, cases were more likely to have had contact with health care services in the last week before death (OR = 4.0, 95% CI = 1.3 - 11.9).

CONCLUSIONS

Suicidal risk is high in Chinese psychiatric patients soon after discharge. They share some common risk factors for suicide identified in Western studies but several differences are evident: the predominance of schizophrenia in the suicides; the lower prevalence of substance abuse and comorbidity; the low proportion of patients living alone; and the increased clinical contact before death but the less suicidal intent expressed in Chinese patients. It is necessary to consider these socio-cultural factors in assessment of suicidal risk and implementation of suicide prevention strategies in Chinese psychiatric patients.