Predicament suicide: an update

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.

Suicidal Thoughts in the Novel Don Quixote

BACKGROUND

During the last century suicide has been medicalised. This restrictive view has been challenged, and the wisdom of experts from beyond medicine is being valued. Fictional literature is a source of information regarding the human experience.

OBJECTIVE

To extend our understanding of suicide and suicidal thinking by examining the early-17th Century Spanish novel, "Don Quixote".

METHOD

Various translations were examined for accounts of suicide, suicidal thinking, and associated behaviour.

RESULTS

There were no accounts of completed suicide. There was one statement indicating the belief that suicide could be triggered by mental disorder. There were five statements indicating that suicidal thinking could arise in situations of distress. Such distress arose from the actual/potential loss of a loved person, suffering by another person, and relentless sleep deprivation. There is one account of a person pretending to attempt suicide and achieving a self-inflicted wound, not with the intention to self-murder, but to impact the disposition of another person.

CONCLUSION

The observation that in early-17th Century Spain suicide was acknowledged as means of dealing with distress is consistent with findings from other periods, and the present day. This strengthens the position that suicide can occur in the absence of mental disorder.