Meta-analysis of suicide rates among psychiatric in-patients

Prison and forensic mental health staff after suicides in their care. A narrative review of international and German national evidence

There is a growing body of international research investigating the impact of patient suicide on mental health professionals. The experience of losing a patient to suicide can have a significant and, in some cases, long-lasting (negative) impact on mental health professionals. However, the nature and extent of the impact on prison staff or forensic mental health professionals in particular is less clear. This narrative review summarises both quantitative and qualitative studies and key findings in this area, focusing on the above professions. A literature search was conducted using PsychInfo and Google Scholar, covering the period from 2000 onwards. The vast majority of findings relate to mental health professionals in general. We were unable to identify any published reports on the responses of forensic psychiatric staff. The majority of identified studies in the prison context are qualitative. Studies from German-speaking countries are particularly scarce in both the prison and mental health contexts. We conclude that there is a profound lack of knowledge about the impact of client/patient suicide on the subgroups of (German) prison and forensic psychiatric staff. Clearly, more research is needed on both the nature and extent of the impact, as well as on the specific organisational and supportive factors that help to mitigate the negative effects of suicide.

A systematic review and thematic synthesis of inpatient nursing staff experiences of working with high-risk patient behaviours

INTRODUCTION

Nursing staff are frequently exposed to high-risk patient behaviours within inpatient health services, yet staff commonly report a lack of training and support in managing these behaviours.

AIM

The aim of the study was to examine nursing staff experiences of high-risk behaviours in inpatient mental health settings.

METHODS

Four electronic databases (CINAHL, Medline, PsycINFO, EMBASE) were searched. The protocol for this review was prospectively registered in PROSPERO (Ref: CRD42022334739). A meta-synthesis of nursing staff's experiences of high-risk behaviours in inpatient mental health settings was conducted.

RESULTS

We identified 30 eligible studies. Six themes were constructed from the meta-synthesis: the social contract of care; the function of risk behaviours; the expectation of risk; risk as a relational concept; navigating contradictions in care; the aftermath.

DISCUSSION

Nursing staff conceptualize risk as a meaningful behaviour shaped by patient, staff and environmental factors. Managing risk is an ethical dilemma for nursing staff and they require more training and support in ethical risk decision-making.

IMPLICATIONS FOR PRACTICE

Inpatient mental healthcare services should formulate and manage risk as a relational concept comprising staff, patient and environmental factors. Future research and clinical practice should place further consideration on the varied experiences of different types of risk behaviours.

RELEVANCE STATEMENT

Nursing staff are frequently exposed to high-risk patient behaviours within inpatient health services, yet staff commonly report a lack of training and support in managing these behaviours. This systematic review offers insights into how high-risk behaviours are experienced by nursing staff and makes recommendations about how to improve the understanding and management of them. Inpatient mental healthcare services should formulate and manage risk as a relational concept comprising staff, patient and environmental factors. Future research and clinical practice should place further consideration on the varied experiences of different types of risk behaviours.

Suicide-preventive compulsory admission is not a proportionate measure - time for clinicians to recognise the associated risks

Suicide is considered a global public health issue and compulsory admission is a commonly used measure to prevent suicide. However, the practice has been criticised since several studies indicate that the measure lacks empirical support and may even increase suicide risk. This paper investigates whether the practice has enough empirical support to be considered proportionate. To that end, arguments supporting compulsory admission as a suicide-preventive measure for most suicidal patients are scrutinized. The ethical point of departure is that the expected benefits of compulsory admission should outweigh the potential harms of the measure to be proportionate and defensible. It is concluded that, for most suicidal patients, suicide-preventive compulsory admission cannot be presumed to be a proportionate measure. To be so, the expected medical benefits of the measure should be greater than the potential increase in suicide risk and other harms that compulsory admission could entail. Instead of using compulsory admission as a suicide-preventive measure, extra safety measures may be needed during and after compulsory admission to prevent the risk of hospitalisation-induced suicide.

Predictors of inpatient suicide in an Irish psychiatric service, a longitudinal case-control study

OBJECTIVE

Inpatient suicide remains difficult to predict. This study aimed to identify individual patient predictors to help identify those at greater risk.

METHODS

This case-control study was undertaken in an independent mental health service in Ireland. Cases were drawn from all admissions to the service between March 2004 and February 2019. Controls were matched for date of admission. Univariate and multivariate analyses were conducted.

RESULTS

Thirty-three cases of inpatient suicide were compared to 132 controls. The inpatient suicide rate was 76.2 per 100,000 admissions. The rate of inpatient suicide fell in line with national rates despite less restrictive practices being implemented in the service. Males accounted for 66% of cases. Hanging was the most common method of suicide overall and among male patients, and drowning was the most common among females. Male gender, tertiary referral, an adverse psychosocial event during admission, a period of absence without leave and expressing hopelessness were identified as independent risk factors for inpatient suicide. Substance use, involuntary detention, family history of suicide, and number of previous admissions were not significant.

CONCLUSIONS

While not highly sensitive, a period of absence without leave, tertiary referral and hopelessness are important predictors of inpatient suicide risk that treating teams should consider in care planning.

Assessment and management of individuals consulting for a suicidal crisis: A European Delphi method-based consensus guidelines

INTRODUCTION

Managing patient with suicidal thoughts and behaviours presents significant challenges due to the scarcity of robust evidence and clear guidance. This study sought to develop a comprehensive set of practical guidelines for the assessment and management of suicidal crises.

MATERIALS AND METHODS

Utilizing the Delphi methodology, 80 suicide clinician and research experts agreed on a series of recommendations. The process involved two iterative rounds of surveys to assess agreement with drafted recommendations, inviting panellists to comment and vote, culminating in 43 consensus recommendations approved with at least 67% agreement. These consensus recommendations fall into three main categories: clinical assessment, immediate care, and long-term approaches.

RESULTS

The panel formulated 43 recommendations spanning suicidal crisis recognition to continuous long-term care. These guidelines underscore systematic proactive suicide risk screening, in-depth medical and toxicological assessment, and suicide risk appraisal considering personal, clinical factors and collateral information from family. The immediate care directives emphasize a secure environment, continuous risk surveillance, collaborative decision-making, including potential hospitalization, sensible pharmacological management, safety planning, and lethal means restriction counselling. Every discharge should be accompanied by prompt follow-up care incorporating proactive case management and multi-modal approach involving crisis lines, brief contact, and psychotherapeutic and pharmacological interventions.

CONCLUSIONS

This study generated comprehensive guidelines addressing care for individuals in suicidal crises, covering pre- to post-discharge care. These practical recommendations can guide clinicians in managing patients with suicidal thoughts and behaviours, improve patient safety, and ultimately contribute to the prevention of future suicidal crises.

Association of suicide with psychiatric hospitalization in Taiwan

INTRODUCTION

A knowledge gap exists in the relationship between suicide and psychiatric hospitalization in Asia. This study investigated inpatient service utilization before suicide and suicide risk at different periods of hospitalization in Taiwan.

METHODS

Using the National Health Insurance Research Database, we applied a nested case-control design with controls being alive on the date each case died by suicide.

RESULTS

A total of 56 939 suicide cases and 1 138 780 controls were included (2:1 male-to-female ratio). Only 5.7% of suicide cases had a history of psychiatric hospitalization in the preceding year. Patients with a history of psychiatric hospitalization were associated with a higher risk of inpatient and postdischarge suicide than those without prior hospitalization. The risk was greatest in the first postdischarge week, decreased gradually, and remained significantly elevated over 7 years after discharge. The suicide risk increased more in females. Patients with affective disorders had higher inpatient and postdischarge suicide risks than those with schizophrenia spectrum disorders.

DISCUSSION

A low rate of psychiatric hospitalization before suicide implies that inpatient treatment of psychiatric disorders could be enhanced. Community-based approaches to suicide prevention can improve the treatment utilization of those with suicide risk and bridge continuous care from hospital to community.

A comparison of inpatient suicides in Australian psychiatric and non-psychiatric hospital units between 2009 and 2018

Hospitalisation is designed to protect patients from harm; however, patients have been reported to take their own lives during hospital admissions. While a significant healthcare concern, few studies have analysed inpatient suicides in general and psychiatric hospital units. Understanding these deaths is important for informing future prevention initiatives. Here we investigate a national sample (n = 367) of inpatient suicides in general (24%, n = 87) and psychiatric (76%, n = 278) hospital units. Patient characteristics, suicide location, timing, and suicide methods were assessed and compared. Patients who died from suicide were mostly male and admitted into psychiatric units. General hospital patients were less likely to have a known history of mental illness or previous self-harm and were often admitted for mental illness-related presentations. Suicides frequently occurred outside of the hospital by hanging. Patients in psychiatric units were more likely to be on approved leave at their death, and general patients were more likely to have absconded. These results indicate the need to identify risk factors relevant to each setting and address broader system-level factors. Removing obvious ligature points, preventing absconding, and assessing patients before episodes of leave, could contribute to preventing inpatient suicides.

Mortality and cause of death during inpatient psychiatric care in New South Wales, Australia: A retrospective linked data study

BACKGROUND

Premature mortality in people with mental illness is well-documented, yet deaths during inpatient psychiatric care have received little research attention. This study investigates mortality rates and causes of death during inpatient psychiatric care in New South Wales (NSW), Australia. Risk factors for inpatient death were also explored.

METHODS

A retrospective cohort study using linked administrative datasets with complete capture of psychiatric admissions in NSW from 2002 to 2012 (n = 421,580) was conducted. Univariate and multivariate random-effects logistic regression analyses were used to explore risk factors for inpatient death.

RESULTS

The mortality rate during inpatient psychiatric care was 1.12 deaths per 1000 episodes of care and appeared to decline over the study period. Suicide accounted for 17% of inpatient deaths, while physical health causes accounted for 75% of all deaths. Thirty percent of these deaths were considered potentially avoidable. In the multivariate model, male sex, unknown address and several physical health diagnoses were associated with increased deaths.

CONCLUSIONS

The mortality rate and number of avoidable deaths during inpatient psychiatric care were substantial and warrant further systemic investigation. This was driven by a dual burden of physical health conditions and suicide. Strategies to improve access to physical health care on psychiatric inpatient wards and prevent inpatient suicide are necessary. A coordinated approach to monitoring psychiatric inpatient deaths in Australia is not currently available and much needed.

Suicide literacy in nurses: A cross-sectional study

AIMS AND OBJECTIVES

This study is a cross-sectional study aiming to determine the suicide literacy level of nurses and to examine the relationship between nurses' suicide literacy and certain variables.

BACKGROUND

Suicide literacy in nurses is a factor which affects knowledge levels. The level of suicide literacy in nurses may affect the care given to patients and the behaviour of obtaining help in relation to themselves.

METHODS

The study was conducted with 348 nurses between January and March 2020 at a hospital in the city of Antalya in Turkey. A personal information form and the Literacy of Suicide Scale (LOSS) were used to collect data. Descriptive statistical methods were used in data analysis. Stepwise multiple linear regression analysis was performed to determine the predictors of suicide literacy. The STROBE checklist was followed for this cross-sectional study.

RESULTS

The nurses' mean score on LOSS was 11.08 ± 3.92. Significant predictors of suicide literacy in nurses were being single, working in the emergency department, having previous experience in the psychiatry clinic, not having a mental illness, having suicide attempts in the family, having previously obtained information on intervention on individuals at risk of suicide and stating that their sources of information on this topic were nursing education and the Internet. These variables explained 19.8% of the variance in suicide literacy.

CONCLUSIONS

The nurses' suicide literacy was at a low level. It is recommended that education programs on the care of patients at risk of suicide be set up for all nurses working in general clinics.

RELEVANCE TO CLINICAL PRACTICE

It is important to raise the levels of suicide literacy in nurses in order to provide better quality care to patients who are at risk of suicide. Also, raising levels of suicide literacy may strengthen nurses' behaviours in seeking help for themselves.

Developing inpatient suicide prevention strategies in medical settings: Integrating literature review with expert testimony

OBJECTIVE

According to some recent evidence, suicide rate is higher in inpatients than in the general population around the world. However, suicide prevention strategies (SPS) are poorly focused and understood in medical settings. This study aimed to develop effective SPS and interventions in medical settings of Iran and provide evaluation checklists/procedures for them.

METHODS

The study was performed in two steps, including literature review and expert opinions panel. In the first stage, we conducted a comprehensive literature review to find relevant suicide prevention programs, strategies, interventions, or any efforts to prevent suicide in the medical settings. In the second stage, an expert panel was arranged for developing effective and feasible SPS in medical settings. Data were analyzed through content analysis approach.

RESULTS

Overall, 11 records were included in the literature review. SPS varied from staff training, safety plan and quality improvements, and prevention programs to therapy methods. Finally, in the second stage, the following seven major SPS were recommended by the expert panel: 1) Integration and application of obtained suicidal behavior data through evaluating medical records, 2) Screening and suicide risk assessment, 3) Staff training, 4) Quality improvement, 5) Follow-up of inpatients with high-risk behaviors, 6) Reducing stigma and improving public awareness, and 7) Follow-up of discharged high-risk inpatients. Also, 23 interventions within the strategies were presented.

CONCLUSION

Given that SPS are poorly focused in medical settings, the practical framework that emerged in this study could be used to develop or advance SPS in various medical settings.

Inpatient suicide in psychiatric settings: Evaluation of current prevention measures

The risk of suicide in psychiatric hospitals is 50 times higher than in the general population, despite patient safety being a priority for any hospital. However, to date, due to the complexity of assessing suicide risk, there has been no consensus on the suicide prevention measures that should be in place in hospitals. The aim of this work is: To provide an overview of the progress that has been made in the field of inpatient suicide prevention in recent years; discuss the problems that remain; and suggest potential future developments. As new clinical dimensions (notably anhedonia, psychological pain and hopelessness) develop, they should become new therapeutic targets. Team training (like the Gatekeeper Training Program) and the latest advances in suicide risk assessment (such as the Collaborative Assessment and Management of Suicidality) should be implemented in psychiatric wards. Suicide prevention plans (e.g., ASSIP, SAFE-T, etc.) represent easy-to-administer, low-cost interventions. The Mental Health Environment of Care Checklist has been proven effective to reduce suicide risk at hospitals. Furthermore, the types of psychotherapy recommended to reduce suicide risk are cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT). There are several pharmacological treatments for suicide risk, such as lithium and clozapine, which have been shown to be effective in the long term, as well as ketamine and esketamine, which are more effective in the short term. Following some encouraging recent results, buprenorphine may also be proposed to patients with a suicide risk. Triple chronotherapy rapidly improves depressive symptoms over 9 weeks. Regarding brain stimulation techniques, rTMS has proven to be effective in alleviating multiple dimensions of suicidality.

Exploring the Objective Signs of Imminent Suicide Risk in Psychiatric In-patients

Objective

This study retrospectively explores the objective signs of imminent suicide risk in psychiatric in-patients.

Design

The study analysed the diagnostic and nursing records of a psychiatric hospital that covered the last 14 days before the suicide attempts of 18 people, who, between March 2008 and July 2019, were found to have died by suicide during their hospital stay.

Methods

Three professionals used a fishbone diagram to separately identify the factors that led to each person's suicide, the objective signs that indicated imminent suicide risk, possible preventive strategies, and other observations. They compared their findings and used the KJ method (Kawakita Jiro Method) to categorise the items on which they all agreed.

Results

Objective signs of imminent suicide risk were condensed into five categories: 'signs emanating from the patient', 'signs gleaned through engagement', 'signs from response to treatment', 'signs associated with reports from the family', and 'signs inferred from multiple sources of information'. Five categories describing issues with the way in which the hospital staff handled information were extracted, namely 'omission in diagnostic records during admission', 'omission in conference records', 'communication lapse during transfer', 'need for integrated information', and 'systemic issues'.

Conclusions

The findings offer insights on assessing suicide risk and preventing suicide.

The impact of service user's suicide on mental health professionals

OBJECTIVES

Our principle objective was to examine the personal and professional impact of service user (SU) suicide on mental health professionals (MHPs). We also wished to explore putative demographic or clinical factors relating to SUs or MPHs that could influence the impact of SU suicide for MHPs and explore factors MHPs report as helpful in reducing distress following SU suicide.

METHODS

A mixed-method questionnaire with quantitative and thematic analysis was utilised.

RESULTS

Quantitative data indicated SU suicide was associated with personal and professional distress with sadness (79.5%), shock (74.5%) and surprise (68.7%) particularly evident with these phenomena lasting less than a year for more than 90% of MHPs. MHPs also reported guilt, reduced self-confidence and a fear of negative publicity. Thematic analysis indicated that some MHPs had greater expertise when addressing SU suicidal ideation and in supporting colleagues after experiencing a SU suicide. Only 17.7% of MHPs were offered formal support following SU suicide.

CONCLUSION

SU suicide impacts MHPs personally and professionally in both a positive and negative fashion. A culture and clear pathway of formal support for MHPs to ascertain the most appropriate individualised support dependent on the distress they experience following SU suicide would be optimal.

Substance use-related suicide after release from correctional, behavioral health, and healthcare facilities using national violent death reporting system data

INTRODUCTION

Suicide and substance use are prevalent problems among persons discharged from facilities. This study (1) articulated rates of substance-related suicide deaths among those discharged correctional, behavioral health, and healthcare facilities, and (2) identified factors associated with substance-related suicide deaths unique to, or generalizing across, facility discharge.

METHODS

We used data from the National Violent Death Reporting System. Suicide deaths (N = 105,968) were aggregated from 2003 to 2017. Chi-square and independent samples t-tests were used to examine associations between drug/alcohol-related deaths and each correlate. Logistic regression was employed to identify the most robust substance-related suicide death-related factors.

RESULTS

Suicide deaths were commonly marked as being substance-related: 69% from correctional institutions, 54% from behavioral health facilities, 45% from those not released from a facility, and 39% from healthcare facilities. Regression models indicated housing interruptions and interpersonal stressors increased odds of the suicide death being marked as substance-related across discharge categories. Each discharge category also had unique predictors, underscoring the need for tailored prevention.

CONCLUSIONS

Substance-related suicide deaths are particularly common among adults discharged from correctional and behavioral health facilities. Findings are discussed with respect to community-focused, discharge planning, and clinical care suicide prevention strategies.

Homicides in psychiatric hospitals: Absence of evidence or evidence of absence?

BACKGROUND

Highly publicised cases of homicide in a psychiatric hospital have raised concerns about the safety of such hospitals.

AIMS

To identify individual case reports of homicides by inpatients within psychiatric hospitals in order to update a 2011 study.

METHODS

A systematic search of the academic literature between 2010 and 2020, information seeking from service leaders in each state and territory of Australia and in New Zealand, and a search of public records in Australia and New Zealand.

RESULTS

The literature search revealed only one recent paper describing a homicide by a patient in a psychiatric ward. Contact with forensic psychiatrists across Australia and New Zealand yielded four cases of inpatient homicide that took place between 2010 and 2017 in Australia, and none in New Zealand. Public record searching did not add to this count. This compares to 11 inpatient homicides by 10 patients between 1985 and 2011.

CONCLUSIONS

Homicides in psychiatric hospitals seem to remain rare, however, there is no consistent central documentation of these events in Australasia so it is hard to be confident about the figures. Internationally, there is similarly little centralisation of evidence. Standardised methods of recording and reporting such deaths might assist the understanding and prevention of homicides in psychiatric hospitals.

Exploring the experience of acute inpatient mental health care from the perspective of family and carers of people experiencing psychosis: A qualitative thematic analysis study conducted during the COVID-19 pandemic

Family and carers play an important role in supporting service users who are in receipt of acute mental health inpatient care, but they can also be significantly emotionally and physically impacted. The aim of this study was to examine their needs and priorities during this time. Fourteen family and carers of inpatients experiencing psychosis completed semi-structured interviews examining their experiences of inpatient care during the COVID-19 pandemic. Thematic analysis was used to analyse data. Four key themes were identified: 'A turbulent journey to hospital admission', 'I need information and support', 'Maintaining my relationship with my loved one' and 'Inpatient care is a mixed bag'. Each theme comprised four or five subthemes. The findings demonstrated that family and carers feel excluded from inpatient care and struggled to maintain contact with their loved ones, which was exacerbated by COVID-19 related restrictions. Communication and being regularly informed about their loved one's care, as well as visiting loved ones, was particularly problematic. Inpatient care needs to be more inclusive of family and carers and ensure they are kept in mind at every stage of the admission.

Telling a Complicated Grief: A Psychodynamic Study on Mental Health Nurses' Countertransference Reactions to Patients' Suicidal Behavior

A key element of suicide education, training and clinical supervision is enhancing emotional awareness about mental health professionals' countertransference reactions, as emotional responses to patients' suicidal behavior (SB) that may be unbeneficial to care. This study aimed to explore emotional responses to patients' SB in mental health nurses (MHNs) according to a psychodynamic perspective. Twenty-eight Italian MHNs (61% females, Mage = 52 years) were interviewed to examine their deep feelings about attempted suicides or deaths by suicide of patients with mental illness. Computer-aided thematic analysis was performed on the verbatim transcribed interviews, adopting Emotional Text Analysis (ETA) as a research framework to explore affective symbolizations underlying narratives, beyond intentional and explicitly reported contents. Some statistical multidimensional techniques were carried out, allowing th.e detection of shared symbolic domains (Cluster Analysis) and latent factors organizing the contraposition between them (Multiple Correspondence Analysis). Five symbolic domains emerged which were respectively referred to as: hyper-vigilance (21.97% of the overall textual corpus), resentment (17.86%), rationalization (34.50%), resignation (5.54%) and mourning (20.12%). Four latent factors explained the overall data variance: strive for reparation (F1), lack of control (F2), ambivalence toward care (F3) and complicated grief (F4). Some clinical recommendations were derived suggesting to balance issues of risk assessment/management and staff's reflective practice, to work on the subjective sense of hopelessness resulting from turning against oneself the hostility evoked by patients, to consider rationalization processes and implicit beliefs leading to risk underestimation and to address some basic conflicts contributing to a complicated grief in mourning suicidal events.

The psychological experiences of nurses after inpatient suicide: A meta-synthesis of qualitative research studies

AIMS

To explore nurses' psychological experiences after inpatient suicide.

DESIGN

Qualitative studies were meta-synthesized.

DATA SOURCES

Eight databases (PubMed, Web of Science, CINAHL, Embase, Wanfang Data, VIP database, CBM and CNKI) were searched for qualitative studies from each database's inception to 31 August 2020.

REVIEW METHODS

Studies were critically appraised using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research. Qualitative data were extracted, summarized, and meta-synthesized.

RESULTS

Eleven studies were included, and five themes were identified: (a) emotional experience, (b) cognitive experience, (c) coping strategies, (d) self-reflection and (e) impact on self and practise.

CONCLUSION

Nurses reported various negative emotions after inpatient suicide. Hospital administrators should recognize nurses' second victim psychological trauma. Moreover, they must develop theory-based education, training and psychological support programmes to promote nurses' mental health. Hospital patient safety management is also important to ensure patient safety whilst preventing nurses from becoming second victims.

IMPACT

Understanding the psychological experiences of nurses who have undergone inpatient suicide will inform future research and practise. Nurses require psychological support after experiencing adverse events. Education and training are necessary to help nurses acquire suicide knowledge, understand the role of the second victim, better cope with adverse events and promote self-growth. Hospitals should strengthen the construction of a safety culture to ensure patient safety.

Clinicians' Experience of Collaboration in the Treatment of Suicidal Clients Within the Collaborative Assessment and Management of Suicidality Framework

INTRODUCTION

There is little known about the clinicians' experience of collaboration using the Collaborative Assessment and Management of Suicide (CAMS) framework. This study aimed to give voice to the clinician experience.

METHOD

A qualitative design utilised semi-structured interviews with ten psychologists who worked in a Suicide Assessment and Treatment Service (SATS) in Ireland which utilises the CAMS framework.

RESULTS

An Interpretative Phenomenological Analysis (IPA) approach revealed several important findings. The superordinate themes included 'Finding Safety', 'Regulation of the Self', 'Connecting', and 'Systemic Challenges'.

DISCUSSION

The CAMS framework plays an important role in providing a safe base for the clinician (in terms of understanding suicidality, in addition to the structures of the framework). It provides a mechanism in which to process difficult emotions, and a way of communicating a formulation of suicide to the treating team. Importantly, the CAMS emerged as facilitating a collaborative, therapeutic way of working.

Prevalence and impact of patient suicide in psychiatrists: Results from a national French web-based survey

BACKGROUND

Patient suicide (PS) is known to be a frequent and challenging occupational hazard for mental health professionals. No study previously explored the prevalence and impact of PS in a large sample of French psychiatrists.

METHOD

A national web-based survey was performed between September and December 2019 to assess (a) the prevalence of the exposure to PS, (b) the emotional, traumatic and professional impacts of PS, and (c) the perceived support in the aftermath of PS in French psychiatrists. Participants were contacted through email to answer the online 62-item questionnaire, including a measure of traumatic impact through the Impact of Event Scale-Revised. Emotional and professional impacts and perceived support were assessed through dedicated items.

RESULTS

A total of 764 psychiatrists fully completed the survey. Of them, 87.3% reported an exposure to PS and 13.7% reported PTSD symptoms afterward. Guilt, sadness and shock were the most frequent emotions. Among the exposed psychiatrists, 15.1% have temporarily considered changing their career path. The most emotionally distressing PS occurred during their ten first years of practice or during residency. A total of 37.1% of respondents felt unsupported and 50.4% reported that no team meeting had been organized in the aftermath. The feeling of responsibility for the death was strongly associated with negative impacts.

CONCLUSION

Our results entail considerations to prevent negative mental health outcomes in psychiatrists after PS. Notably, our results advocate for the implementation of educational programs during psychiatric residency and postvention programs in healthcare settings to effectively help psychiatrists in dealing with PS.

High suicide rates during psychiatric inpatient stay and shortly after discharge

OBJECTIVE

Over recent decades, intense efforts to address suicides in psychiatric admitted people have been initiated. The aim was to calculate suicide rates, rate ratios, population attributable risks (PAR) and trends among people admitted to or recently discharged from psychiatric wards.

METHODS

Using a cohort design, we obtained nationwide register data on 6 292 932 individuals aged 15+ living in Denmark during 1995-2016. Of these, 178 703 (5.73%) males and 201 033 females (6.33%) had been admitted to psychiatric hospital. Incidence rate ratios (IRR) were obtained using Poisson regression analyses while adjusting for age and calendar period. Trends were assessed using joinpoint analyses.

RESULTS

In total, 15 075 persons died by suicide, of which 6174 had been psychiatrically admitted. Among males, the suicide rate during the first week of admission and after discharge was 3409 and 3148 per 100 000 person-years, respectively. The corresponding values for females were 1267 and 1631. Generally, estimated suicide rates were highest in those with affective or anxiety stress disorders. During first week of hospitalization, the IRR was 237 for males and of 322 for females when compared with those never hospitalized. In first week after discharge, the IRR was 225 and 425 for males and females, respectively. PAR estimates indicated 6% of male suicides and 13% of female suicides attributes to first week of admission and discharge. The inpatient suicide rate decreased annually 2.5% until 2009 followed by a 7.5% annual percentage increase. The suicide rate after discharge decreased steadily annually over the study period.

CONCLUSION

Despite finding declining post-discharge suicide rates, the period surrounding a psychiatric admission was still associated with extremely high suicide rates.

Clinical and personality profile of depressed suicide attempters: A preliminary study at the open-door policy Mood Disorder Unit of San Raffaele Hospital

Suicidal behavior is a complex phenomenon with high rates among psychiatric inpatients. Mood disorders and personality dysfunctions represent relevant risk factors for suicides attempts and suicidal ideation. Our study aims to investigate the role of the co-occurrence of clinical variables (duration of depressive state, previous suicide attempts), socio-demographic variables (gender, employment and civil status) and narcissistic personality features in the suicide risk of admitted psychiatric patients affected by a mood disorder. The sample was composed of 93 patients consecutively admitted in an open ward psychiatric Unit. Forty-eight participants had a positive history of previous suicide attempts: the suicide attempters (SA) were mostly female, unemployed and married. The SA group were observed to have suffered from a depressive episode with a longer duration; moreover in the SA group, the presence of active suicidal ideation was significantly related to a higher number of previous suicide attempts. In the whole sample, suicidal ideation was significantly related to narcissistic vulnerability personality features. Using a multidimensional approach, the present study allows a preliminary profiling of patients at risk for suicidal behavior during hospitalization.

Length of stay in relation to the risk of inpatient and post-discharge suicides: A national health insurance claim data study

BACKGROUND

This study aimed to compare the predictors of suicides among psychiatric inpatients and recently discharged patients and to examine the association between the length of stay and suicides.

METHODS

Data from psychiatric inpatients were extracted from the National Health Insurance databank and merged with information from the Cause of Death data using unique identification numbers. Poisson regression analyses were used to estimate the incidence rate ratio for inpatient and post-discharge suicides, which included the variables of sex, age, psychiatric diagnosis, and number of admissions in the preceding year. The associations between length of stay and inpatient and post-discharge suicide were examined using multivariate Poisson regression analyses that were adjusted for these variables.

RESULTS

A diagnosis of affective disorders and a higher number of previous admissions increased both inpatient and post-discharge suicides. Patients older than 15-24 years had a significantly lower inpatient suicide risk but were more likely to die by suicide post-discharge. The risk of suicide both during the inpatient stay and post-discharge statistically significantly decreased when the length of stay was longer.

LIMITATIONS

As there were variations in societal, environmental, and facility-level factors that might have influenced the association between length of stay and suicide, the generalization of our findings to different settings may be impeded.

CONCLUSIONS

This study provides additional evidence that hospitalization helps to reduce the suicide risk. It suggests that medical professionals should be alert to inpatient suicide and that they should determine the optimal length of stay considering post-discharge suicide.

Recognizing states of psychological vulnerability to suicidal behavior: a Bayesian network of artificial intelligence applied to a clinical sample

BACKGROUND

This study aimed to determine conditional dependence relationships of variables that contribute to psychological vulnerability associated with suicide risk. A Bayesian network (BN) was developed and applied to establish conditional dependence relationships among variables for each individual subject studied. These conditional dependencies represented the different states that patients could experience in relation to suicidal behavior (SB). The clinical sample included 650 mental health patients with mood and anxiety symptomatology.

RESULTS

Mainly indicated that variables within the Bayesian network are part of each patient's state of psychological vulnerability and have the potential to impact such states and that these variables coexist and are relatively stable over time. These results have enabled us to offer a tool to detect states of psychological vulnerability associated with suicide risk.

CONCLUSION

If we accept that suicidal behaviors (vulnerability, ideation, and suicidal attempts) exist in constant change and are unstable, we can investigate what individuals experience at specific moments to become better able to intervene in a timely manner to prevent such behaviors. Future testing of the tool developed in this study is needed, not only in specialized mental health environments but also in other environments with high rates of mental illness, such as primary healthcare facilities and educational institutions.

Future Directions in Single-Session Youth Mental Health Interventions

The United States spends more money on mental health services than any other country, yet access to effective psychological services remains strikingly low. The need-to-access gap is especially wide among children and adolescents, with up to 80% of youths with mental health needs going without services, and the remainder often receiving insufficient or untested care. Single-session interventions (SSIs) may offer a promising path toward improving accessibility, cost-effectiveness, and completion rates for youth mental health services. SSIs are structured programs that intentionally involve only one visit or encounter with a clinic, provider, or program; they may serve as stand-alone or adjunctive clinical services. A growing body of evidence supports the capacity of SSIs to reduce and prevent youth psychopathology of multiple types. Here, we provide a working definition of SSIs for use in future research and practice; summarize the literature to date on SSIs for child and adolescent mental health; and propose recommendations for the future design, evaluation, and implementation of SSIs across a variety of settings and contexts. We hope that this paper will serve as an actionable research agenda for gauging the full potential of SSIs as a force for youth mental health.

Preventing Suicide among Psychiatric Inpatients with Psychotic Depression

To investigate which factors individuals with a psychotic depression experience as preventive of suicide while beeing hospitalized. Semi-structured qualitative interviews with nine inpatients, all hospitalized for a unipolar or bipolar depressive episode with psychosis, were conducted at time of discharge. For analysis we used systematic text condensation. Main outcomes were accounts of participants' experiences of suicide prevention measures and treatment, and how these affected suicidal ideation, plans, and attempts. Participants experienced (1) suicide attempts being physically interrupted or prevented; (2) receiving medical treatment to alleviate unbearable suffering; (3) finding refuge behind locked doors; (4) receiving guidance to redefine their identity and situation. They reported being protected from suicidal impulses and imagined persecutors in a secure environment with staff present. They described their autonomy as compromised by intense suffering and chaos. They retrospectively appreciated staff interventions, if these were performed compassionately and with empathy. Participants described that suicidal thoughts and actions were triggered by terrifying psychotic experiences, anxiety and sleeplessness, and felt that medication - and in one instance electroconvulsive therapy- alleviated suffering. At time of discharge, participants reported no psychotically motivated suicidal thoughts. They described a new, insightful self-view and acknowledged having been severely mentally ill. To prevent impulsive suicidal behavior, findings highlight the need for both security measures and a treatment approach focusing on modifying psychotic experiences and intense anxiety. Gaining anxious and paranoid patients' trust is essential to build motivation for medical treatment. Patients emphasize that having time to talk is crucial to this process.

Demographic Risk Factors for Suicide among Youths in The Netherlands

In 2000 to 2016 the highest number of suicides among Dutch youths under 20 in any given year was 58 in 2013. In 2017 this number increased to 81 youth suicides. To get more insight in what types of youths died by suicide, particularly in recent years (2013-2017) we looked at micro-data of Statistics Netherlands and counted suicides among youths till 23, split out along gender, age, regions, immigration background and place in household and compared this to the general population of youths in the Netherlands. We also compared the demographics of young suicide victims to those of suicide victims among the population as a whole. We found higher suicide rates among male youths, older youths, those of Dutch descent and youths living alone. These differences were generally smaller than in the population as a whole. There were also substantial geographical differences between provinces and healthcare regions. The method of suicide is different in youth compared to the population as a whole: relatively more youth suicides by jumping or lying in front of a moving object and relatively less youth suicides by autointoxication or drowning, whereas the most frequent method of suicide among both groups is hanging or suffocation.

Suicides in Psychiatric Patients: Identifying Health Care-Related Factors through Clinical Practice Reviews

The objective of this study was to identify health care-related factors associated with death by suicide in psychiatric patients and to gain insight into clinician views on how to deal with suicidality. The study material derived from a clinician committee in a psychiatric department reviewing every outpatient and inpatient suicide in a standardized way. Reports' conclusions and corresponding plenary discussion minutes regarding 94 suicides were analyzed using inductive thematic content analysis. Health care-related factors were categorized into 4 themes: patient evaluation, patient management, clinician training, and involvement of relevant non-clinical partners. Clinician views on the themes were expressed through statements (i) promoting or restricting an aspect of care (here called recommendations), which mainly followed existing guidelines and were consensual and (ii) without precise indication (here called comments), which departed from mainstream opinions or addressed topics not covered by existing policy. Involvement of non-clinical partners emerged as a new key issue for suicide prevention in psychiatric departments and should be openly discussed with patients. Clinicians preferred balanced conclusions when they reviewed suicide cases.

Suicide in Psychiatric Inpatients- A Case-Control Study

Objective: Psychiatric inpatients constitute a population at considerably increased risk for suicide. Identifying those at imminent risk is still a challenging task for hospital staff. This retrospective case-control study focused on clinical risk factors related to the course of the hospital stay. Method: Inpatient suicide cases were identified by linking the Tyrol Suicide Register with the registers of three psychiatric hospitals in the state. Control subjects were patients who had also been hospitalized in the respective psychiatric unit but had not died by suicide. Matching variables included sex, age, hospital, diagnosis, and admission date. The study period comprised 7 years. Data were analyzed by the appropriate two-sample tests and by logistic regression. Results: A total of 30 inpatient suicide cases and 54 control patients were included. A number of factors differentiated cases from controls; after correction for multiple testing, the following retained significance: history of aborted suicide, history of attempted suicide, history of any suicidal behavior/threats, suicidal ideation continuing during hospitalization, no development of prospective plans, no improvement of mood during the hospital stay, and leaving ward without giving notice. Logistic regression identified the latter three variables and history of attempted suicide as highly significant predictors of inpatient suicide. Conclusions: Preventive measures during hospitalization include thorough assessment of suicidal features, an emphasis on the development of future perspectives, and a review of hospital regulations for patients who want to leave the ward.

Suicide prediction models: a critical review of recent research with recommendations for the way forward

Suicide is a leading cause of death. A substantial proportion of the people who die by suicide come into contact with the health care system in the year before their death. This observation has resulted in the development of numerous suicide prediction tools to help target patients for preventive interventions. However, low sensitivity and low positive predictive value have led critics to argue that these tools have no clinical value. We review these tools and critiques here. We conclude that existing tools are suboptimal and that improvements, if they can be made, will require developers to work with more comprehensive predictor sets, staged screening designs, and advanced statistical analysis methods. We also conclude that although existing suicide prediction tools currently have little clinical value, and in some cases might do more harm than good, an even-handed assessment of the potential value of refined tools of this sort cannot currently be made because such an assessment would depend on evidence that currently does not exist about the effectiveness of preventive interventions. We argue that the only way to resolve this uncertainty is to link future efforts to develop or evaluate suicide prediction tools with concrete questions about specific clinical decisions aimed at reducing suicides and to evaluate the clinical value of these tools in terms of net benefit rather than sensitivity or positive predictive value. We also argue for a focus on the development of individualized treatment rules to help select the right suicide-focused treatments for the right patients at the right times. Challenges will exist in doing this because of the rarity of suicide even among patients considered high-risk, but we offer practical suggestions for how these challenges can be addressed.

Using Administrative Data to Predict Suicide After Psychiatric Hospitalization in the Veterans Health Administration System

There is a very high suicide rate in the year after psychiatric hospital discharge. Intensive postdischarge case management programs can address this problem but are not cost-effective for all patients. This issue can be addressed by developing a risk model to predict which inpatients might need such a program. We developed such a model for the 391,018 short-term psychiatric hospital admissions of US veterans in Veterans Health Administration (VHA) hospitals 2010-2013. Records were linked with the National Death Index to determine suicide within 12 months of hospital discharge (n=771). The Super Learner ensemble machine learning method was used to predict these suicides for time horizon between 1 week and 12 months after discharge in a 70% training sample. Accuracy was validated in the remaining 30% holdout sample. Predictors included VHA administrative variables and small area geocode data linked to patient home addresses. The models had AUC=.79-.82 for time horizons between 1 week and 6 months and AUC=.74 for 12 months. An analysis of operating characteristics showed that 22.4%-32.2% of patients who died by suicide would have been reached if intensive case management was provided to the 5% of patients with highest predicted suicide risk. Positive predictive value (PPV) at this higher threshold ranged from 1.2% over 12 months to 3.8% per case manager year over 1 week. Focusing on the low end of the risk spectrum, the 40% of patients classified as having lowest risk account for 0%-9.7% of suicides across time horizons. Variable importance analysis shows that 51.1% of model performance is due to psychopathological risk factors accounted, 26.2% to social determinants of health, 14.8% to prior history of suicidal behaviors, and 6.6% to physical disorders. The paper closes with a discussion of next steps in refining the model and prospects for developing a parallel precision treatment model.

'Promoting and preserving safety and a life-oriented perspective': A qualitative study of nurses' interactions with patients experiencing suicidal ideation

Suicide prevention is an important imperative in psychiatric hospitals, where nurses have a crucial role in and make essential contributions to suicide prevention and promoting the recovery of patients experiencing suicidal ideation. The present qualitative grounded theory study aimed to uncover and understand the actions and aims of nurses in psychiatric hospitals during their interactions with patients experiencing suicidal ideation. Interviews were conducted with 26 nurses employed on 12 wards in four psychiatric hospitals. The data analysis was inspired by the Qualitative Analysis Guide of Leuven. The findings show that nurses' actions and aims in their interactions with patients experiencing suicidal ideation are captured in the core element 'promoting and preserving safety and a life-oriented perspective'. This core element represents the three interconnected elements 'managing the risk of suicide', 'guiding patients away from suicidal ideation', and 'searching for balance in the minefield'. The enhanced understanding of nurses' actions and aims can inform concrete strategies for nursing practice and education. These strategies should aim to challenge overly controlling and directing nursing approaches and support nurses' capacity and ability to connect and collaborate with patients experiencing suicidal ideation.

Risk for suicide nursing diagnosis and its related risk factors, in psychiatric settings: A descriptive study

AIM

To assess the frequency of risk for suicide nursing diagnosis and its related risk factors, in the nursing care provided in psychiatric settings.

DESIGN

This is a descriptive study.

METHODS

The samples were the documented nursing reports. These reports were evaluated and analysed in terms of using the NANDA-I risk for suicide nursing diagnosis and the risk factors related to this diagnosis.

RESULTS

From the 1,440 reports that were reviewed, 10 nursing diagnoses and 478 risk factors, were identified. Based on the results of this study, risk for suicide is used at a very low level in psychiatric settings, while, considerable number of suicide's risk factors are still existing in these settings.

Suicidality among child and adolescent psychiatric inpatients: time trend study comparing 2000 and 2011

Child and adolescent inpatient treatment has faced major changes since the year 2000, including shorter inpatient stays and a greater use of psychotropic drugs. This study explored changes and correlates of suicidal threats and suicide acts among inpatients, by comparing Finnish cross-sectional surveys from 2000 to 2011. A questionnaire that explored the background, diagnosis and treatment characteristics of inpatients was sent to all child and psychiatric wards in Finland. The data collection was carried out on specified days in 2000 and 2011. We received comprehensive data on 504 patients from 64/69 (93%) wards in 2000 and on 412 patients from 75/79 (95%) wards in 2011. The Spectrum of Suicidal Behaviour Scale was used to explore suicidality. The prevalence of suicidality did not change in this nationwide study: suicidal threat rates were 38% in 2000 and 37% in 2011, and suicide attempts in both years were 11%. The prevalence of suicidal acts was higher among girls and teenagers, while low general functioning, defined as Children's Global Assessment Scale scores of under 30, was associated with both suicidal threats and acts. Violent acts were associated with both suicidal threats and acts in 2000, but not in 2011. Despite changes in treatment practices and shorter inpatient stays, the prevalence of suicidality in child and adolescent inpatient treatment remained unchanged in Finland in 2000 and 2011.

Rates and trends of psychiatric inpatient and postdischarge suicides in Taiwan, 2002-2013: a national register-based study

PURPOSE

In contrast to the downsizing trend of psychiatric beds in the Western world, the psychiatric bed capacity in Taiwan has steadily increased in recent decades. This study aimed to assess the suicide rates and their variations over time among psychiatric inpatients and recently discharged patients.

METHODS

Data on psychiatric inpatients admitted from 2002 to 2013 were extracted from the psychiatric inpatient registry of the National Health Insurance and merged with information from the Cause of Death data by means of unique identified numbers. Suicides occurring during admission and within 90 days after discharge were defined as inpatient and postdischarge suicides, respectively. Calendar year was fitted as a continuous variable in multivariate Poisson regression models to evaluate these rates over time. The analyses were adjusted for sex, age, primary psychiatric diagnosis, and number of admissions in the preceding year.

RESULTS

The overall inpatient suicide rate was very low (81 per 100,000 person-years). It decreased significantly from 146 to 74 per 100,000 person-years over the study period. This fall was observed among both genders and across all psychiatric diagnoses. The postdischarge suicide rate was comparatively high (1108 per 100,000 person-years) and did not show statistically significant change over the study period.

CONCLUSIONS

Our results suggest that efforts to increase public awareness of mental disorders and efficient utilization of psychiatric inpatient care are essential for suicide prevention despite the comparatively high bed capacity. The discharge plans of inpatients should be bridged with population suicide prevention programs for continuity of care after discharge.

The role of prediction in suicide prevention

It is widely believed that suicide prevention involves the consideration of risk and protective factors and related interventions. Preventative interventions can be classified as “universal” (targeting whole populations), “selective” (targeting higher-risk groups), and “indicated” (protecting individuals). This review explores the range of preventative measures that might be used commensurately with different types of suicide prediction. The author concludes that the best prospects for suicide prevention lie in universal prevention strategies. While risk assessments do generate some information about future suicide, suicide risk categorization results in an unacceptably high false positive rate, misses many fatalities, and therefore, is unable to usefully guide prevention strategies. The assessment of suicidal patients should focus on contemporaneous factors and the needs of the patient, rather than probabilistic notions of suicide risk.

Closer to the Truth: Admission to Multiple Psychiatric Facilities and an Inaccurate History of Hospitalization Are Strongly Associated with Inpatient Suicide

OBJECTIVE

To investigate clinical associations within Canadian psychiatric inpatient suicides.

METHOD

We conducted a case-control study comparing 98 patients who died by suicide while in hospital and 196 similarly admitted living inpatient controls. All were admitted to an Ontario psychiatric bed between 2008 and 2015 inclusive and had data collected at admission using the Resident Assessment Instrument for Mental Health (RAI-MH). The data were analyzed with bivariate tests and logistic regression modeling.

RESULTS

The strongest associations with inpatient suicide were prior admission to any Ontario psychiatric bed within the previous 30 days (odds ratio [OR] = 6.13), self-harm assessed at prior admission to a psychiatric hospital other than the hospital of suicide (OR = 6.07), and prior admission to a psychiatric hospital other than the hospital of suicide in the previous year (OR = 5.38). A multivariate model using risk factors assessed at admission had an area under the curve (AUC) of 0.77. The model improved to (AUC) 0.81 using a retrospective search of all Ontario admissions to more accurately detect prior admissions. The risk model was optimized to (AUC) 0.83 when the model also included a "discrepancy" variable to denote records in which admission assessment data and retrospective search data did not agree regarding past month admissions.

CONCLUSIONS

In addition to the well-known risks of suicide associated with previous suicide attempts and depressive conditions, our data suggest a particular risk of inpatient suicide associated with inpatient care in more than one hospital, particularly when the treating clinicians were unaware of recent previous admissions.

Suicide risk assessment among psychiatric inpatients: a systematic review and meta-analysis of high-risk categories

BACKGROUND

The clinical care of psychiatric patients is often guided by perceptions of suicide risk. The aim of this study was to examine the methods and results of studies reporting high-risk models for inpatient suicide.

METHODS

We conducted a registered meta-analysis according to PRISMA guidelines. We searched for relevant peer-reviewed cohort and controlled studies indexed in Medline, EMBASE and PsychINFO.

RESULTS

The pooled odds ratio (OR) among 18 studies reporting high-risk models for inpatient suicide was 7.1 [95% confidence interval (CI) 4.2-12.2]. Between-study heterogeneity in ORs was very high (range 0-94.8, first quartile 3.4, median 8.8, third quartile 26.1, prediction interval 0.80-63.1, I2 = 88.1%). The meta-analytically derived sensitivity was 53.1% (95% CI 38.2-67.5%, I2 = 95.9%) and specificity was 84.2% (95% CI 71.6-91.9%, I2 = 99.9%) with an associated meta-analytic area under the curve of 0.83. The positive predictive value of risk categorization among six cohort studies was 0.43% (95% CI 0.014-1.3%, I2 = 95.9%). A history of suicidal behavior and depressive symptoms or affective disorder was included in the majority of high-risk models.

CONCLUSIONS

Despite the strength of the pooled association between high-risk categorization and suicide, the very high degree of observed heterogeneity indicates uncertainty about our ability to meaningfully distinguish inpatients according to suicide risk. The limited sensitivity and low positive predictive value of risk categorization suggest that suicide risk models are not a suitable basis for clinical decisions in inpatient settings.

Psychiatric hospitalisation and the risk of suicide

The association between current or recent psychiatric hospitalisation and increased suicide risk is well described. This relationship is generally assumed to be due to the selection of people at increased risk of suicide for psychiatric admission and subsequent failure of protection from suicide once admitted. Here, Matthew Large and Nav Kapur debate whether or not admission to hospital also selects for vulnerability to certain harmful aspects of hospitalisation and whether the increased rate of suicide in current and recently discharged psychiatric patients is, in fact, due to psychiatric hospitalisation itself.Declaration of interestM.M.L. has provided expert testimony in legal proceedings following in-patient suicide. N.K. sits on the Department of Health (England) National Suicide Prevention Strategy Advisory group.

The investigation of the relationship between probability of suicide and reasons for living in psychiatric inpatients

AIM

This study was carried out to determine the reasons of the suicide probability and reasons for living of the inpatients hospitalized at the psychiatry clinic and to analyze the relationship between them.

MATERIALS AND METHODS

The sample of the study consisted of 192 patients who were hospitalized in psychiatric clinics between February and May 2016 and who agreed to participate in the study. In collecting data, personal information form, suicide probability scale (SPS), reasons for living inventory (RFL), and Beck's depression inventory (BDI) were used. Stepwise regression method was used to determine the factors that predict suicide probability.

RESULTS

In the study, as a result of analyses made, the median score on the SPS was found 76.0, the median score on the RFL was found 137.0, the median score on the BDI of the patients was found 13.5, and it was found that patients with a high probability of suicide had less reasons for living and that their depression levels were very high. As a result of stepwise regression analysis, it was determined that suicidal ideation, reasons for living, maltreatment, education level, age, and income status were the predictors of suicide probability (F = 61.125; P < 0.001).

DISCUSSION

It was found that the patients who hospitalized in the psychiatric clinic have high suicide probability and the reasons of living are strong predictors of suicide probability in accordance with the literature.

Suicide Rates After Discharge From Psychiatric Facilities: A Systematic Review and Meta-analysis

Importance

High rates of suicide after psychiatric hospitalization are reported in many studies, yet the magnitude of the increases and the factors underlying them remain unclear.

Objectives

To quantify the rates of suicide after discharge from psychiatric facilities and examine what moderates those rates.

Data Sources

English-language, peer-reviewed publications published from January 1, 1946, to May 1, 2016, were located using MEDLINE, PsychINFO, and EMBASE with the search terms ((suicid*).ti AND (hospital or discharg* OR inpatient or in-patient OR admit*).ab and ((mortality OR outcome* OR death*) AND (psych* OR mental*)).ti AND (admit* OR admis* or hospital* OR inpatient* OR in-patient* OR discharg*).ab. Hand searching was also done.

Study Selection

Studies reporting the number of suicides among patients discharged from psychiatric facilities and the number of exposed person-years and studies from which these data could be calculated.

Data Extraction and Synthesis

The meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. A random-effects model was used to calculate a pooled estimate of postdischarge suicides per 100 000 person-years.

Main Outcomes and Measures

The suicide rate after discharge from psychiatric facilities was the main outcome, and the association between the duration of follow-up and the year of the sampling were the main a priori moderators.

Results

A total of 100 studies reported 183 patient samples (50 samples of females, 49 of males, and 84 of mixed sex; 129 of adults or unspecified patients, 20 of adolescents, 19 of older patients, and 15 from long-term or forensic discharge facilities), including a total of 17 857 suicides during 4 725 445 person-years. The pooled estimate postdischarge suicide rate was 484 suicides per 100 000 person-years (95% CI, 422-555 suicides per 100 000 person-years; prediction interval, 89-2641), with high between-sample heterogeneity (I2 = 98%). The suicide rate was highest within 3 months after discharge (1132; 95% CI, 874-1467) and among patients admitted with suicidal ideas or behaviors (2078; 95% CI, 1512-2856). Pooled suicide rates per 100 000 patients-years were 654 for studies with follow-up periods of 3 months to 1 year, 494 for studies with follow-up periods of 1 to 5 years, 366 for studies with follow-up periods of 5 to 10 years, and 277 for studies with follow-up periods longer than 10 years. Suicide rates were higher among samples collected in the periods 1995-2004 (656; 95% CI, 518-831) and 2005-2016 (672; 95% CI, 428-1055) than in earlier samples.

Conclusions and Relevance

The immediate postdischarge period is a time of marked risk, but rates of suicide remain high for many years after discharge. Patients admitted because of suicidal ideas or behaviors and those in the first months after discharge should be a particular focus of concern. Previously admitted patients should be able to access long-term care and assistance.

Should compulsory admission to hospital be part of suicide prevention strategies?

The World Health Organization report Preventing Suicide: A Global Imperative provides governments with guidance for comprehensive suicide prevention strategies. However, it does not mention the role that compulsory admission to hospital of psychiatric patients should have in policies for suicide prevention. This was a missed opportunity for international discussion and guidance about a measure that, although widely used, is becoming increasingly controversial in light of the existing evidence and human rights norms.

In-patient suicide: selection of people at risk, failure of protection and the possibility of causation

BACKGROUND

Being a current psychiatric in-patient is one of the strongest statistical risk factors for suicide. It is usually assumed that this strong association is not causal but is a result of the combination of the selection of high-risk patients for admission and the imperfect protection from suicide afforded by psychiatric wards. Logically, a third factor, which is causal, might play a role in the association. It has recently been suggested that adverse experiences in psychiatric units such as trauma, stigma and loss of social role might precipitate some in-patient suicides.

AIMS

To consider whether there is a causal association between psychiatric hospitalisation and suicide.

METHOD

We used the framework of Austin Bradford Hill's criteria for assessing causality in epidemiology to consider the possibility that psychiatric hospitalisation might causally contribute to the extent and variation in in-patient suicide rates.

RESULTS

The association between psychiatric hospitalisation and suicide clearly meets five of the nine Hill's criteria (strength of association, consistency, plausibility, coherence and analogy) and partially meets three of the remaining four criteria (gradient of exposure, temporality and experimental evidence).

CONCLUSIONS

Admission to hospital itself might play a causal role in a proportion of in-patient suicides. The safety of being in hospital with respect to suicide could be examined with a large-scale randomised controlled trial (RCT). In the absence of an RCT, the possibility of a causal role provides further impetus to calls to make care in the community more available and psychiatric hospitals more acceptable to patients.

DECLARATION OF INTEREST

M.M.L. and C.J.R. have provided expert testimony in legal proceedings following in-patient suicide.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Suicide Behaviors in Adult Inpatients with Mental Disorders in Beijing, China

Background: This study examined the tendency and suicidal behavior rates of Chinese adult inpatients with different types of mental disorders from 2010 to 2015. The aim was to provide some interesting clues for further studies. Methods: Adult patients with mental disorders who were hospitalized in Beijing Anding hospital from 1 January 2010 to 31 December 2015 were included. Chi-square tests were used to compare the difference among inpatients with mental disorders by gender and year. Frequency, trend and suicidal behavior rates of inpatients with mental disorders were graphed. Results: A total of 17,244 psychiatric adult inpatients were included in our study. About 53.2% of the inpatients had mood disorders, followed by schizophrenia, which accounted for 34.6%. The proportion of female inpatients with mental disorders was larger than that of males (52.6% to 47.4%). Of the total, 3296 psychiatric inpatients were recognized as having suicidal behaviors. The rate of suicidal behavior among all inpatients was 19.1%, and it varied over the years. The suicidal behavior rate of female inpatients with mood disorders was much higher than that of the corresponding male inpatients. Conclusions: The presence of suicidal behavior varied among people with different types of mental disorders. For each type of mental illness, identifying the risk of specific suicide behavior would help tailor-make preventive efforts accordingly.