The Wessex Recent In-Patient Suicide Study, 1. Case-control study of 234 recently discharged psychiatric patient suicides

Implementation of caring contacts using patient feedback to reduce suicide-related outcomes following psychiatric hospitalization

INTRODUCTION

Suicide risk is substantially elevated following discharge from a psychiatric hospitalization. Caring Contacts (CCs) are brief communications delivered post-discharge that can help to improve mental health outcomes.

METHOD

This three-phase, mixed-method quality-improvement study revised an existing CC intervention using iterative patient and community feedback. Inpatients (n = 2) and community members (n = 13) participated in focus groups to improve existing CC messages (phases 1 and 2). We piloted these messages among individuals with a suicide-related concern following discharge from an inpatient psychiatric hospitalization (n = 27), sending CCs on days 2 and 7 post-discharge (phase 3). Phase 3 participants completed mental health symptom measures at baseline and day 7, and provided feedback on these messages.

RESULTS

Phase 1 and 2 focus group participants indicated preferences for shorter, more visually appealing messages that featured personalized, recovery-focused content. Phase 3 participants demonstrated reductions in depressive symptoms at day-7 post-discharge (-6.4% mean score on Hopkins-Symptom-Checklist, -9.0% mean score on Entrapment-Scale). Most participants agreed that CC messages helped them feel more connected to the hospital and encouraged help-seeking behavior post-discharge.

CONCLUSION

This study supports the use of an iterative process, including patient feedback, to improve CC messages and provides further pilot evidence that CC can have beneficial effects.

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.

Continuity of care in suicide prevention: current status and future directions

Introduction

Continuity of Care (CoC) is central to suicide prevention. The present study aims to review contemporary definitions, operationalization in research, and key components of CoC in the prevention of suicide.

Methods

The present study is a narrative review. A thorough search of available literature on CoC and suicidality was conducted. Studies published between 1995 and 2021 were reviewed and selected based on relevance to CoC and suicidality. Selected research was subsequently summarized to outline definitions of CoC, its operationalization in research, and key components for suicide prevention.

Results

The definition, measurement, and operationalization of CoC in suicide prevention varies tremendously, derailing clinical practice. Key elements of CoC identified across the literature include (1) CoC across multiple levels of care, (2) the role of primary care providers and case managers in CoC of suicidal patients, (3) the importance of follow up contact with suicidal patients post-treatment, and (4) the role of national and institutional guidelines for CoC of suicidal patients. Limitations: There is a dearth of randomized controlled trials and insufficient evidence on specific populations.

Conclusion

CoC refers to a wide, complex concept that must be broken down into specific categories that can provide more nuanced guidance of research and clinical implications.

Cause-specific mortality after discharge from inpatient psychiatric care in Taiwan: A national matched cohort study

AIMS

We aimed to investigate the trajectories of absolute and relative risks of cause-specific mortality among patients discharged from inpatient psychiatric services.

METHODS

We conducted a national matched cohort study (2002-2013) using data from the Taiwan National Health Insurance database linked to national cause-of-death data files. Patients discharged from inpatient psychiatric care without prior psychiatric hospitalizations were individually matched to 20 comparison individuals based on sex and age. The rates, rate differences, and relative risks (hazard ratios, HRs) of cause-specific mortality were calculated at six follow-up periods post-discharge. Cumulative mortality incidence was assessed at 5 years of follow-up.

RESULTS

The mortality risks of all causes were increased among patients (n = 158 065) relative to comparison individuals (n = 3 161 300). Mortality rate differences were greater for natural causes, while relative risks (HRs) were higher for unnatural causes. Suicide was the leading cause of death within the first year of discharge, while circulatory and respiratory diseases were the leading causes of death from the second year. The mortality rates and HRs for all causes of death (except homicide) were highest during the first 3 months. The elevated risk of unnatural-cause mortality declined rapidly after discharge but remained high in the long term; in contrast, risk elevation for natural-cause mortality was more stable over time. Approximately one-eighth of patients (12.9%, 95% confidence interval 12.7-13.7%) died within 5 years of follow-up.

CONCLUSIONS

Integrated physical and mental health care is needed to reduce excess mortality, particularly during the first 3 months post-discharge, among psychiatric patients.

Opioid use as a proximal risk factor for suicidal behavior in young adults

INTRODUCTION

There is a concomitant rise in suicide rates with the prevalence of opioids involved in overdose deaths, especially among adolescents and young adults. However, there are limited studies on whether opioid use prospectively predicts suicidal behavior in youth.

METHODS

Our sample included 183 psychiatric patients (18-30 years) admitted for a suicide attempt (SA), have current suicidal ideation (SI), and psychiatric controls without ideation or attempt (PC). Suicidal behavior was assessed using the Columbia Suicide Severity Rating Scale. We also recruited a healthy control group (HC; n = 40). Patients and controls were followed over a year. ANOVA, regression, and cox regression were used.

RESULTS

Suicide attempt (β = 0.87, CI [0.1-1.6], p = 0.02) and SI [(β = 0.75, CI [0.03-1.5], p = 0.04) were significantly more likely than HCs to have used opioids in the past year at baseline. Opioid use was associated with increased anxiety symptoms (β = 0.75, CI [0.001-1.5], p = 0.05), PTSD symptoms (β = 3.90, CI [1.1-6.7], p = 0.01), and aggression (β = 0.02, CI [0.01-0.04], p = 0.02). Opioid use in the month prior to hospitalization predicted SA at 6 months (OR = 1.87, CI [1.06-3.31], p = 0.032).

CONCLUSIONS

Opioid use is a proximal predictor for SA. These findings may help clinicians better identify patients at risk for suicidal behavior, allowing for more personalized treatment approaches.

Risk of suicide after discharge from inpatient psychiatric care: a systematic review

OBJECTIVE

The period following discharge from inpatient psychiatric care is recognised as an especially high-risk time for patient suicide. Astonishingly, there is a dearth of comprehensive studies examining risk and protective factors in this specific population. The aim of this study was to establish the protective and risk factors for suicide in the first year post-discharge (PD) from psychiatric facilities and their utility in categorising patients as high or low risk in a meaningful way to benefit clinical care and improve patient outcomes.

METHODS

A methodical search of three databases (PubMed, EMBASE, and PsychINFO) was used to identify reports describing risk factors for suicide after psychiatric discharge.

RESULTS

Predominantly, male sex, a history of self-harm, a history of suicide attempts, admission with suicidal ideation or suicidal behaviour, and hopelessness were identified as being associated with death by suicide after discharge. Lithium appeared to be protective against suicide in the studies reviewed. Other variables examined showed mixed results.

CONCLUSIONS

The findings of this review suggest that significant suicide predictors both common and unique to those established for suicide in the general population exist and can be utilised in a clinically meaningful way, despite the difficulties inherent in studying this population.KEY POINTSThe risk of suicide after psychiatric hospitalisation is high.Factors that predict suicide after psychiatric hospitalisation overlap only partially with risk factors for suicide in general.Important risk factors for suicide in the post-discharge period include male sex, a history of self-harm, a history of suicide attempts, the presence of suicidal ideation during the admission, and hopelessness.The conclusions that can be drawn from the existing literature are limited by small study sizes, different study populations, and different follow-up periods; additional research in this domain is needed.

Meta-analysis of the strength of exploratory suicide prediction models; from clinicians to computers

BACKGROUND

Suicide prediction models have been formulated in a variety of ways and are heterogeneous in the strength of their predictions. Machine learning has been a proposed as a way of improving suicide predictions by incorporating more suicide risk factors.

AIMS

To determine whether machine learning and the number of suicide risk factors included in suicide prediction models are associated with the strength of the resulting predictions.

METHOD

Random-effect meta-analysis of exploratory suicide prediction models constructed by combining two or more suicide risk factors or using clinical judgement (Prospero Registration CRD42017059665). Studies were located by searching for papers indexed in PubMed before 15 August 2020 with the term suicid* in the title.

RESULTS

In total, 86 papers reported 102 suicide prediction models and included 20 210 411 people and 106 902 suicides. The pooled odds ratio was 7.7 (95% CI 6.7-8.8) with high between-study heterogeneity (I2 = 99.5). Machine learning was associated with a non-significantly higher odds ratio of 11.6 (95% CI 6.0-22.3) and clinical judgement with a non-significantly lower odds ratio of 4.7 (95% CI 2.1-10.9). Models including a larger number of suicide risk factors had a higher odds ratio when machine-learning studies were included (P = 0.02). Among non-machine-learning studies, suicide prediction models including fewer risk factors performed just as well as those including more risk factors.

CONCLUSIONS

Machine learning might have the potential to improve the performance of suicide prediction models by increasing the number of included suicide risk factors but its superiority over other methods is unproven.

Assessment of Suicide Risks During the First Week Immediately After Discharge From Psychiatric Inpatient Facility

Background: The suicide rate in first week after psychiatric discharge is alarmingly high. Although a risk assessment prior to discharge is standard praxis, it can be difficult to take into consideration the obstacles that patient will meet once discharged. A follow-up-visit during the first week after discharge is an opportunity to reevaluate whether a person may be at risk of suicide. Aim: To determine how many patients, of those who were assessed, were evaluated to be at elevated risk of suicide during the first week after psychiatric discharge and secondarily to identify predictors of this and predictors for receiving a follow-up visit during first week after discharge. Methods: All patients discharged between March 1st 2018 to January 17th 2019 were offered a home visit including a systematic risk assessment. Socio-demographics and clinical variables were obtained from medical records and logistic regression analyses were used to identify predictors of a higher suicide risk assessment as well as receiving a follow-up visit. Results: Information from 1905 discharges were included. Of these, 1,052 were seen in follow-up meetings. Risk assessments was conducted in a total of 567 discharge procedures, of which 28 (5%) had an elevated risk of suicide. A history of suicide attempt, suicide risk having been the reason for admission, a first diagnosis of a psychiatric disorder was associated with an elevated risk of suicide after discharge. Conclusion: Follow-up visits could serve as an important tool to identify people whose suicidal risk were overlooked at discharge or exposed to severe stressors after discharge.

Association of continuity of care with readmission, mortality and suicide after hospital discharge among psychiatric patients

Objectives

The objective of this study was to identify the association between continuity of ambulatory psychiatric care after hospital discharge among psychiatric patients and readmission, mortality and suicide.

Design

Nationwide nested case-control study.

Settings

South Korea.

Participants

Psychiatric inpatients.

Interventions

Continuity of psychiatric outpatient care was measured from the time of hospital discharge until readmission or death occurred, using the continuity of care index.

Main Outcome Measures

Readmission, all-cause mortality and suicides within 1-year post-discharge.

Results

Of 18 702 psychiatric inpatients in the study, 8022 (42.9%) were readmitted, 355 (1.9%) died, and 108 (0.6%) died by suicide within 1 year after discharge. Compared with the psychiatric inpatients with a high continuity-of-care score, a significant increase in the readmission risk within 1 year after discharge was found in those with medium and low continuity of care scores. An increased risk of all-cause mortality within 1 year after hospital discharge was shown in the patients in the low continuity group, relative to those in the high-continuity group. The risk of suicide within 1 year after hospital discharge was higher in those with medium and low continuity of care than those with high continuity of care.

Conclusion

The results of this study provide empirical evidence of the importance of continuity of care when designing policies to improve the quality of mental health care, such as increasing patient awareness of the importance of continuity and implementation of policies to promote continuity.

A regional systems intervention for suicide prevention in the Netherlands (SUPREMOCOL): study protocol with a stepped wedge trial design

BACKGROUND

In the Netherlands, suicide rates showed a sharp incline and this pertains particularly to the province of Noord-Brabant, one of the southern provinces in the Netherlands. This calls for a regional suicide prevention effort.

METHODS/DESIGN

Study protocol. A regional suicide prevention systems intervention is implemented and evaluated by a stepped wedge trial design in five specialist mental health institutions and their adherent chain partners. Our system intervention is called SUPREMOCOL, which stands for Suicide Prevention by Monitoring and Collaborative Care, and focuses on four pillars: 1) recognition of people at risk for suicide by the development and implementation of a monitoring system with decision aid, 2) swift access to specialist care of people at risk, 3) positioning nurse care managers for collaborative care case management, and 4) 12 months telephone follow up. Eligible patients are persons attempting suicide or expressing suicidal ideation. Primary outcome is number of completed suicides, as reported by Statistics Netherlands and regional Public Health Institutes. Secondary outcome is number of attempted suicides, as reported by the regional ambulance transport and police. Suicidal ideation of persons registered in the monitoring system will, be assessed by the PHQ-9 and SIDAS questionnaires at baseline and 3, 6, 9 and 12 months after registration, and used as exploratory process measure. The impact of the intervention will be evaluated by means of the RE-AIM dimensions reach, efficacy, adoption, implementation, and maintenance. Intervention integrity will be assessed and taken into account in the analysis.

DISCUSSION

The present manuscript presents the design and development of the SUPREMOCOL study. The ultimate goal is to lower the completed suicides rate by 20%, compared to the control period and compared to other provinces in the Netherlands. Moreover, our goal is to provide specialist mental health institutions and chain partners with a sustainable and adoptable intervention for suicide prevention.

TRIAL REGISTRATION

Netherlands Trial Register under registration number NL6935 (5 April 2018). This is the first version of the study protocol (September 2019).

Update on the management of alcohol use disorders

Alcohol use disorders (AUD) are common, particularly in patients attending mental health services. Clinicians are often hesitant to explore with patients their relationship with alcohol and the role that it has in their presenting complaint, despite being ideally placed to optimise on a ‘teachable moment’ and initiate treatment, where necessary. This article provides an overview of AUD and their identification and management options.

Change Management in Health Care and Mental Health Nursing

Since Nightingale implied that progress was inherent in good nursing, change has slowly but surely accelerated to a frenetic pace in health care and to a degree in nursing. However, the healthy progress and implications associated with change in the nursing profession are not as readily embraced as this pace may imply. Rather, embracing change at the core of nursing and health care is a challenge as this is a group who it is suggested are not only resistant but also adept at reinforcing the status quo. Using mental health nursing as an example this position paper addresses the concept of change management, explores the facilitators and inhibitors to explain why change is not effectively managed at times. Further, case studies provided exemplify how change in mental health nursing has occurred and demonstrate how the concept of change management effectively has been achieved. Key strategies for change management are outlined in this article, noting the need to be sensitive to the culture and specifics of that organisation, because change takes place within people rather than within the organisation itself. Part of the challenges and strategies faced in the profession are related to the movement of information and knowledge from the point of research to implementation of evidence-based best practice. Leaders, therefore, should adopt change management principles and strategies, to further drive the developments which have changed mental health nursing over a relatively short period.

Does Compulsory Admission Prevent Inpatient Suicide Among Patients with Schizophrenia? A Nationwide Cohort Study in Taiwan

OBJECTIVE

The aim of this study was to analyze the risk of inpatient suicide in patients with schizophrenia during 2007-2013 and to determine putative risk factors.

METHODS

We conducted a national population-based cohort study of 2,038 psychiatric inpatients in their first compulsory admission, matched with 8,152 controls who were voluntary inpatients. Only patients with schizophrenia were included in the study. We used data derived from the Taiwanese National Health Insurance Database 2005, comprising 1 million beneficiaries randomly selected from the entire population of Taiwan.

RESULTS

During the follow-up period, 23 and 75 inpatient suicides were observed in the compulsory and control groups, respectively. Kaplan-Meier curves showed that the cumulative incidence rate of inpatient suicide was not significantly different between compulsory and voluntary admissions (log-rank test, p = .206).

CONCLUSIONS

Our results suggest that compulsory admission has no protective effects on risk reduction of inpatient suicide for patients with schizophrenia who are compulsorily admitted compared with voluntarily admitted controls. Clinicians should be more alert for the prevention of inpatient suicide among patients with schizophrenia and consider the close monitoring of inpatient suicide risk in the first week of admission.

Association between continuity of care and subsequent hospitalization and mortality in patients with mood disorders: Results from the Korea National Health Insurance cohort

Concerns have been raised about the loss of treatment continuity in unipolar and bipolar depressive disorder patients as continuity of care (COC) may be associated with patient outcomes. This study aimed to examine the relationship between COC and subsequent hospitalization, all-cause mortality, and suicide mortality in individuals with unipolar and bipolar disorder. Data were from the National Health Insurance (NHI) cohort, 2002 to 2013. Study participants included individuals first diagnosed with unipolar depressive disorder or bipolar affective disorder. The independent variable was COC for the first year of outpatient visits after diagnosis, measured using the usual provider of care (UPC) index. The dependent variables were hospitalization in the year after COC measurement, all-cause mortality, and suicide mortality. Analysis was conducted using logistic regression and Cox proportional hazards survival regression. A total of 48,558 individuals were analyzed for hospitalization and 48,947 for all-cause and suicide mortality. Compared to the low COC group, the medium [odds ratio (OR) 0.30, 95 percent confidence interval (95% CI) 0.19–0.47] and the high COC group (OR 0.14, 95% CI 0.09–0.21) showed statistically significant decreased odds of hospitalization. Additionally, lower likelihoods of suicide death were found in the high (HR 0.35, 95% CI 0.16–0.74) compared to the low COC group. The results infer an association between COC after first diagnosis of unipolar or bipolar depressive disorder and hospitalization and suicide mortality, suggesting the potential importance of treatment continuity in improving patient outcomes.

Risk factors for suicide in bipolar disorder: a cohort study of 12 850 patients

OBJECTIVE

Bipolar disorder carries a high risk of suicide. Identification of risk factors is important. The aim of this study was to study risk factors for suicide in a large cohort of men and women with bipolar disorder.

METHOD

A prospective cohort study using clinical data from the Swedish National Quality Register for Bipolar Affective Disorder (BipoläR). The outcome variable was suicide captured in the Cause of Death Register between 2004 and 2014. Hazard ratios (HR) were calculated using Cox proportional hazards models.

RESULTS

Of 12 850 persons (4844 men and 8006 women) with bipolar disorder, 90 (55 men and 35 women) died by suicide during the follow-up period (between 1 and 10 years). Male sex (HR 2.56), living alone (HR 2.45), previous suicide attempts (HR 4.10), comorbid psychiatric disorder (HR 2.64), recent affective episodes (HR 2.39), criminal conviction (HR 4.43), psychiatric inpatient care (HR 2.79), and involuntary commitment (HR 3.50) were significant risk factors for suicide. Several of the statistically significant risk factors for suicide in bipolar disorder differed between men and women.

CONCLUSIONS

Risk factors for suicide in bipolar disorder include factors associated with suicide in general, but also diagnosis-specific factors.

Suicidal ideation and subsequent completed suicide in both psychiatric and non-psychiatric populations: a meta-analysis

AIMS

Several authors claimed that expression of suicidal ideation is one of the most important predictors of completed suicide. However, the strength of the association between suicidal ideation and subsequent completed suicide has not been firmly established in different populations. Furthermore, the absolute suicide risk after expression of suicidal ideation is unknown. In this meta-analysis, we examined whether the expression of suicidal ideation predicted subsequent completed suicide in various populations, including both psychiatric and non-psychiatric populations.

METHODS

A meta-analysis of cohort and case-control studies that assessed suicidal ideation as determinant for completed suicide in adults. Two independent reviewers screened 5726 articles for eligibility and extracted data of the 81 included studies. Pooled risk ratios were estimated in a random effects model stratified for different populations. Meta-regression analysis was used to determine suicide risk during the first year of follow-up.

RESULTS

The risk for completed suicide was clearly higher in people who had expressed suicidal ideation compared with people who had not, with substantial variation between the different populations: risk ratio ranging from 2.35 (95% confidence interval (CI) 1.43-3.87) in affective disorder populations to 8.00 (95% CI 5.46-11.7) in non-psychiatric populations. In contrast, the suicide risk after expression of suicidal ideation in the first year of follow-up was higher in psychiatric patients (risk 1.40%, 95% CI 0.74-2.64) than in non-psychiatric participants (risk 0.23%, 95% CI 0.10-0.54). Past suicide attempt-adjusted risk ratios were not pooled due to large underreporting.

CONCLUSIONS

Assessment of suicidal ideation is of priority in psychiatric patients. Expression of suicidal ideation in psychiatric patients should prompt secondary prevention strategies to reduce their substantial increased risk of suicide.

Suicide following discharge from in-patient psychiatric care

The risk of suicide is higher during the period immediately following discharge from in-patient psychiatric care than at any other time in a service user's life. Demographic and clinical risk factors for suicide in this period are similar to those for suicide at other times and may not be specific enough to enable identification of those at greatest risk. Epidemiological studies suggest that factors related to service organisation and delivery (e.g. social support and continuity of care) are also important in the aetiology of suicide following hospital discharge. Interventions aimed at helping people in the period immediately following discharge from in-patient care have been developed. Although the effect of these interventions on suicidal behaviour has not been examined, available evidence suggests that efforts to increase patients' confidence and level of social support may be of value.

OPUS study: Suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis

Background

Patients with first-episode psychosis comprise a high-risk group in terms of suicide.

Aims

To identify predictive factors for suicidal behaviour and to examine the effect of integrated treatment on suicidal behaviour and hopelessness.

Method

A total of 341 patients with a first-episode schizophrenia-spectrum disorder were randomised to integrated treatment or treatment as usual.

Results

During the 1-year follow-up period, 11% attempted suicide. This was associated with female gender, hopelessness, hallucinations and suicide attempt reported at baseline, with the two latter variables being the only significant ones in the final multivariate model. The integrated treatment reduced hopelessness.

Conclusions

Hallucinations and suicide attempt before inclusion in the study were the most significant predictors of suicide attempt in the follow-up period.

Predictors of short-term repetition of self-harm among patients admitted to an emergency room following self-harm: A retrospective one-year cohort study

We conducted a retrospective chart-review study, examining predictors of the repetition of short-term self-harm (<1 month and <6 months) among the patients who were admitted to an emergency department in Japan following self-harm. A total of 405 patients were enrolled and were followed-up for a subsequent one year. The incidence of repeated self-harm within one- and six- months were 6.4% and 13.1%, respectively. Cox's proportional hazards model analyses demonstrated that history of self-harm and comorbid physical illness were associated with repeated self-harm within one month. The patients who lived alone and who were directly discharged from the emergency room after referral to a psychiatrist were at higher risk for repeated self-harm within both one and six months. Living on public assistance and having been discharged from psychiatric wards within the past 12 months were associated with repetition within six months. These risk factors should be incorporated into routine assessment at an emergency room, and elaborate follow-up plan should be provided to the patients with these risk factors upon discharge from the emergency room. Further prospective studies are warranted, addressing more comprehensive factors that are associated with short-term risk for self-harm and suicide.

Medically Documented Suicide Ideation Among U.S. Army Soldiers

We used administrative data to examine predictors of medically documented suicide ideation (SI) among Regular Army soldiers from 2006 through 2009 (N = 10,466 ideators, 124,959 control person-months). Enlisted ideators (97.8% of all cases) were more likely than controls to be female, younger, older when entering service, less educated, never or previously deployed, and have a recent mental health diagnosis. Officer ideators were more likely than controls to be female, younger, younger when entering service, never married, and have a recent mental health diagnosis. Risk among enlisted soldiers peaked in the second month of service and declined steadily, whereas risk among officers remained relatively stable over time. Risk of SI is highest among enlisted soldiers early in Army service, females, and those with a recent mental health diagnosis.

Taking care of suicidal patients with new technologies and reaching-out means in the post-discharge period

Suicide is a global public health problem with over one million people dying by suicide each year worldwide. Research efforts have focused on developing and testing novel suicide prevention strategies employing recent technological advances. In order to provide a review regarding the role of new technologies (e.g., postcards/letters, text messages, crisis cards, telephone contacts, online interventions) in suicide prevention, we searched PubMed, ScienceDirect, ResearchGate, and Crisis to identify all papers in English from 1977 to 2016. Our results indicated that brief contact interventions show promise in reducing the number of episodes of repeated self-harm and/or suicide attempts following discharge from the Emergency Department or psychiatric units. Innovative methods of contact (e.g., text messages) are easily implemented by clinicians and received by patients in the period of post discharge and have been shown to be beneficial. However, more research employing randomized clinical trials investigating the potential benefits of these novel suicide prevention methods is warranted. Future researchers should continue improving and testing new technologies in the prevention of suicide.

Testing a Theory-Based Model of Suicidality in a Community Sample

The aim of the present study is to test a theory-based model of suicide in a low-risk nonclinical sample. A community sample of convenience of 200 adults, 102 men and 98 women, responded to the Depressive Experiences Questionnaire, the Center for the Epidemiologic Studies of Depression Scale, the Psychache Scale, the Interpersonal Needs Questionnaire, and the Suicide Behaviors Questionnaire Revised. The hypothesized structural equation model, including trait dimensions of self-criticism and neediness, and state dimensions of depression, psychache, perceived burdensomeness, and thwarted belongingness, fit the observed data well and significantly explained 49% of the variance of suicidality.

"When you're in the hospital, you're in a sort of bubble." Understanding the high risk of self-harm and suicide following psychiatric discharge: a qualitative study

BACKGROUND

Individuals are at a greatly increased risk of suicide and self-harm in the months following discharge from psychiatric hospital, yet little is known about the reasons for this.

AIMS

To investigate the lived experience of psychiatric discharge and explore service users' experiences following discharge.

METHOD

In-depth interviews were undertaken with recently discharged service users (n = 10) in the UK to explore attitudes to discharge and experiences since leaving hospital.

RESULTS

Informants had mixed attitudes to discharge, and those who had not felt adequately involved in discharge decisions, or disagreed with them, had experienced urges to self-harm since being discharged. Accounts revealed a number of factors that made the postdischarge period difficult; these included both the reemergence of stressors that existed prior to hospitalization and a number of stressors that were prompted or exacerbated by hospitalization.

CONCLUSION

Although inferences that can be drawn from the study are limited by the small sample size, the results draw attention to a number of factors that could be investigated further to help explain the high risk of suicide and self-harm following psychiatric discharge. Findings emphasize the importance of adequate preparation for discharge and the maintenance of ongoing relationships with known service providers where possible.

Factors associated with adult poisoning in Northern Malaysia: a case-control study

Data on adult risk factors associated with drug or chemical poisonings in Malaysia are scarce. The objective of the study was to identify possible risk factors associated with adult admissions to the Penang General Hospital (PGH) due to chemical poisoning and/or drug overdose. The present study was a case-control study, conducted over 18 weeks. One hundred acutely poisoned adult patients admitted to PGH during the period from September 2003 to February 2004 were considered as cases. Two hundred patients admitted to the same medical wards for other illnesses, during the same period, were matched for age and gender with the poisoned cases and thus selected as controls. McNemar test and binary logistic were used for univariate analysis and logistic regression analysis for multivariate analyses. The odds ratio (OR) and its 95% confidence interval (95% CI) were calculated for each predictor variable. Positive histories of psychiatric illness and previous poisoning, problems in boy/girl friend relationships, family problems, marital problems, Indian ethnicity, Chinese ethnicity, living in rented houses and living in a household with less than five people were significant risk factors associated with adult admissions due to poisoning.

Self-report depressive symptoms do not directly predict suicidality in nonclinical individuals: Contributions toward a more psychosocial approach to suicide risk

Although suicidality is associated with mental illness in general and depression in particular, many depressed individuals do not attempt suicide and some individuals who attempt to or do die by suicide do not present depressive symptoms. This article aims to contribute to a more psychosocial approach to understanding suicide risk in nonclinical populations. In advocating a psychosocial perspective rather than a depression-focused approach, this article presents four diverse studies that demonstrate sampling and measurement invariance in findings across different populations and specific measures. Study 1 tests the mediation effects of 2 interpersonal variables, thwarted belongingness and perceived burdensomeness, in the association between depressive symptoms and recent suicidality. Studies 2 and 3 evaluate the contribution of hopelessness and psychache, beyond depressive symptoms, to suicidality. Study 4 tests the contribution of life events behind depressive symptoms, and other relevant sociodemographic and clinical variables, to the estimation of "future suicidality." Overall, results demonstrate that depressive symptoms do not directly predict suicidality in nonclinical individuals, but that other psychosocial variables mediate the association between depressive symptoms and suicidality or predict suicidality when statistically controlling for depressive symptoms. The article contributes to understanding some of the nonpsychopathological factors that potentially link depressive symptoms to suicide risk and that might themselves contribute to suicidality, even when controlling for depressive symptoms.

Negative cognitions about the self in patients with persecutory delusions: An empirical study of self-compassion, self-stigma, schematic beliefs, self-esteem, fear of madness, and suicidal ideation

There has been growing awareness of the high prevalence of negative cognitions about the self in patients with persecutory delusions, and it has been proposed that paranoid fears build upon these perceived vulnerabilities. This study aimed to investigate for the first time a wide range of different conceptualisations of the negative self, and to examine associations with suicidal ideation, in patients with persecutory delusions. Twenty-one patients with persecutory delusions and twenty-one non-clinical individuals completed measures relating to negative self cognitions. The delusions group also completed a measure of suicidal ideation. It was found that the patients with persecutory delusions had low self-compassion, low self-esteem, increased fears of being mad, beliefs of inferiority to others, negative self-schemas, and low positive self-schemas when compared to the non-clinical control group. The effect sizes (Cohen's d) were large, and the different conceptualisations of negative self cognitions were highly associated with one another. Self-stigma did not differ between the two groups. Furthermore, suicidal ideation was highly associated with low self-compassion, low self-esteem, fears of madness, and negative self-schema but not self-stigma. This study shows marked negative self cognitions in patients with persecutory delusions. These are likely to prove targets of clinical interventions, with patient preference most likely determining the best conceptualisation of negative self cognitions for clinicians to use.

Investigating the validity and usability of an interactive computer programme for assessing competence in telephone-based mental health triage

Telephone-based mental health triage services are frontline health-care providers that operate 24/7 to facilitate access to psychiatric assessment and intervention for people requiring assistance with a mental health problem. The mental health triage clinical role is complex, and the populations triage serves are typically high risk; yet to date, no evidence-based methods have been available to assess clinician competence to practice telephone-based mental health triage. The present study reports the findings of a study that investigated the validity and usability of the Mental Health Triage Competency Assessment Tool, an evidence-based, interactive computer programme designed to assist clinicians in developing and assessing competence to practice telephone-based mental health triage.

Diagnoses and prescriptions of antidepressants in suicides: Register findings from the Friuli Venezia Giulia Region, Italy, 2002-2008

OBJECTIVE

To explore to what extent and under which diagnoses individuals who committed suicide had received psychiatric in-patient care, and how many had previously committed non-lethal self-harm. To investigate the antidepressant treatment received by these individuals.

METHODS

Case-control study based on a health register.

RESULTS

Psychiatric hospitalisation was found in 31.2% of the cases and 2.3% of the controls, and was a strong predictor for suicide with an odds ratio (OR) = 19.5. This did not differ significantly between diagnostic categories (except anxiety disorders with OR = 5.3). Non-lethal self-harm in the study period was committed by 14.3% of the cases and 0.14% of the controls, and was twice as common in female cases than in male cases. Previous self-harm was a very strong independent predictor for suicide with OR = 53.1 when a single episode of self-harm had occurred, and OR = 98.0 for repeated episodes (adjusted for age, gender and hospitalisation). Only 16.1% of the cases were currently on antidepressant medication at the time of suicide.

CONCLUSIONS

Few of the suicides had previously been psychiatric in-patients. Even fewer had current prescriptions for antidepressants. This suggests that better diagnosis and treatment of psychiatric patients is an important suicide preventive intervention.

Personality vulnerabilities in adolescent suicidality: The mediating role of psychological distress

The research literature consistently indicates that self-criticism is related to suicidality. Evidence for the role of dependency, however, is more controversial. This study examines the extent to which these personality vulnerabilities are mediated by psychological distress in the prediction of suicidality. As part of a study of adolescent psychopathology, a sample of 260 Portuguese adolescents (148 [56.9 %] female and 112 [43.1%] male), ranging in age from 15 to 18 years (M = 16.32, SD = 1.19) completed measures of personality, suicidal behavior, and current distress, in counterbalanced order. The measures were: self-criticism and dependency from the Depressive Experiences Questionnaire for Adolescents; two psychological distress scales, social withdrawal from the Youth Self Report and depression from the Center for Epidemiologic Studies of Depression Scale; and a measure of suicidality from the Suicide Behaviors Questionnaire Revised. Structural equation modeling indicated that self-criticism and dependency were both significantly associated with suicidality. Psychological distress, however, as measured by withdrawal and depression, fully mediated these relationships, but did not moderate them. The authors conclude that adolescents with higher levels of self-criticism and dependency are at greater risk for experiencing intense psychological distress-high levels of social withdrawal and depression-that account for their vulnerability to suicide risk.

Testing Models Relating Rejection, Depression, Interpersonal Needs, and Psychache to Suicide Risk in Nonclinical Individuals

OBJECTIVES

Using structural equation modeling, we tested a primary model of suicide risk and 3 competing, alternative models based on 4 psychological variables deemed important in the literature (perception of parental rejection, depression, interpersonal needs comprising perceived burdensomeness and thwarted belongingness, and psychache), in a nonclinical sample of Portuguese adults.

METHOD

A convenience sample of 203 adults (100 men, 103 women; aged 18-65 years) participated in this study.

RESULTS

Analyses demonstrated that the proposed primary model had the best fit to the observed data. The differences in fit indexes for this model and one of the alternative models, however, were not substantial.

CONCLUSION

Perceived parental rejection related directly to suicide risk and indirectly via depression and interpersonal needs. Depression linked indirectly to suicide risk via interpersonal needs and psychache. Interpersonal needs related directly to suicide risk and indirectly via psychache, which related directly to suicide risk.

Determinants of completed railway suicides by psychiatric in-patients: case-control study

BACKGROUND

Suicide prediction during psychiatric in-patient treatment remains an unresolved challenge.

AIMS

To identify determinants of railway suicides in individuals receiving in-patient psychiatric treatment.

METHOD

The study population was drawn from patients admitted to six psychiatric hospitals in Germany during a 10-year period (1997-2006). Data from 101 railway suicide cases were compared with a control group of 101 discharged patients matched for age, gender and diagnosis.

RESULTS

Predictors of suicide were change of therapist (OR = 22.86, P = 0.004), suicidal ideation (OR = 7.92, P<0.001), negative or unchanged therapeutic course (OR = 7.73, P<0.001), need of polypharmaceutical treatment (OR = 2.81, P = 0.04) and unemployment (OR = 2.72, P = 0.04). Neither restlessness nor impulsivity predicted in-patient suicide.

CONCLUSIONS

Suicidal ideation, unfavourable clinical course and the use of multiple psychotropic substances (reflecting the severity of illness) were strong determinants of railway suicides. The most salient finding was the vital impact of a change of therapist. These findings deserve integration into the clinical management of patients with serious mental disease.

Psychiatric and psycho-social characteristics of suicide completers: a comprehensive evaluation of psychiatric case records and postmortem findings

Objectives

To explore the demographic, psychosocial and clinical characteristics of individuals known to the mental health services, who died by probable suicide in the West of Ireland.

Methods

Postmortem reports between January 2006 and May 2012 detailed 153 individuals who died by probable suicide, 58 of whom attended the mental health services. Relevant socio-demographic and clinical data was extracted from individuals’ lifetime case notes.

Results

Recurrent depressive disorder (44%) was the most common diagnosis and hanging the most common method of death (58%). Of individuals who died by hanging, 79% previously attempted suicide by the same method. For individuals with a documented history of depression, only 32% had antidepressants detected in their toxicology reports. Similarly, only one individual (20%) with schizophrenia had antipsychotics detected in their toxicology report.

Conclusions

Individuals who died by probable suicide, most commonly died by hanging and drowning; with previous attempts of hanging particularly prevalent in the group who subsequently died by hanging. At the time of death, less than one-third of individuals according to toxicology reports were taking the medication that was last prescribed to them by the mental health services suggesting a high rate of treatment non-concordance in individuals who died by probable suicide.

APSI: a proposed integrative model for suicide prevention

BACKGROUND

Deaths by suicide have been increasing in recent years in Ireland, many of whom have co-morbid mental health difficulties and/or have attended primary care services 1 month before death. Aims To profile how 'Access to Psychological Services Ireland' (APSI) provides stepped-care therapies for mild-to-moderate adult mental health presentations and the potential effectiveness of this model based on comparison to a review of evidence-based strategies in suicide prevention. A secondary aim is to highlight how APSI has the potential to target those at risk of suicide and provide an integrative after-care service to complement secondary care mental health services. Findings In a context of inter-agency working, APSI provides an integrated continuum of suicide prevention interventions that map onto or intervene across the continuum of suicide behaviour. Hence, APSI appears to implement what the literature suggests will work in preventing suicide. However, outcome research is needed to establish APSI's impact in preventing suicide. Recommendations It is recommended that Irish-based research is conducted to establish APSI's impact in preventing suicide with a view to rolling out APSI as a national mental health clinical care programme.

A review of evidence-based follow-up care for suicide prevention: where do we go from here?

CONTEXT

Follow-up services are an important component of a comprehensive, national strategy for suicide prevention. Increasing our knowledge of effective follow-up care has been identified as an Aspirational Goal by The National Action Alliance for Suicide Prevention's Research Prioritization Task Force.

EVIDENCE ACQUISITION

Several recent comprehensive reviews informed the selection of studies included in this brief review. Studies of follow-up services that reported significant effects for the outcomes of death by suicide, suicide attempts, or suicidal ideation were included.

EVIDENCE SYNTHESIS

Although there is a paucity of research in this area, promising paradigms that have demonstrated effectiveness in preventing suicide and suicide attempts and reducing suicidal ideation will be discussed. The major limitations of the literature in this area include numerous methodological flaws in the design and analyses of such studies and the lack of replication of studies with positive findings.

CONCLUSIONS

This paper identifies several breakthroughs that would be helpful for advancing this area of research and describes a comprehensive research pathway for achieving both short- and long-term research objectives.

The Isle of Wight Suicide Study: a case study of suicide in a limited geographic area

BACKGROUND

Suicide is a major public health problem, with mental disorders being one of its major risk factors. The high incidence of suicide on the Isle of Wight has motivated this study, the first of its kind on suicide in this small geographic area. Aim The aim of the study was to identify socio-demographic and clinical risk factors for suicide in the population of service users and non-service users, and gender-related characteristics of suicidal behaviour in a limited geographic region.

METHOD

Data were collected on 68 cases of suicide (ICD-10×60-X84) from residents of the Isle of Wight District between January 2006 and December 2009. All data were statistically analysed using Pearson's χ 2 test and Yates' correction for continuity.

RESULTS

The mean annual suicide rates over the period were 5.65 per 100 000 for women and 19.28 for men. Significantly (p=0.0006), more men than women (male/female ratio 3:1) died as a result of suicide. Relatively (p=0.07) more women (56.2%) than men (32.7%), and significantly more (p=0.05) service users (45.3%) than non-service users (13.3%) were unemployed. Significantly, more (p=0.0006) service users (64%) than non-service users (20%) had a history of suicide attempts and relatively (p=0.06) more (50.9%) service users than non-service users (20%) had attended the accident and emergency department before their death; 69% had an adverse life event within a year before their suicide. Depression as the most common Axis-I illness was diagnosed in 36% of all; but significantly (p=0.008) more in women (66.6%) than men (17.3%). Relatively (p=0.07) more women (56.2%) than men (32.7%) have contacted services before their death. Suicide by hanging was the most common cause, accounting for the death of 71% of men and 50% of women.

CONCLUSIONS

The study found that 80% of all suicides occurred in people suffering from mental disorder. Men are at a significant risk of suicide. Depressive disorders in women and stress-related disorders in men were the most common mental disorders. Treating mental disorders and co-morbid conditions seems to be one of the key elements in suicide prevention strategies.

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.

Suicide mortality and risk factors in the 12 months after discharge from psychiatric inpatient care in Korea: 1989-2006

This study aimed to determine the suicide mortality within 1 year after discharge from psychiatric inpatient care and identify the risk factors for suicide completion during this period. A total of 8403 patients were admitted to general hospitals in Seoul, Korea, for psychiatric disorders from January 1989 to December 2006. The suicide mortality risk of these patients within 1 year of discharge was compared with that of gender- and age-matched subjects from the general population of Korea. The standardized mortality ratios (SMR) for suicide in the year following discharge were 49.7 for males and 45.5 for females. Patients aged 15-24 years had the highest risk for suicide. Among the different diagnostic groups, patients with personality disorders, schizophrenia, or affective disorders had the highest risk for suicide completion. Suicidal ideation at admission and inpatient stay more than 1 month were also associated with increased risk of suicide. In Korean psychiatric patients, the SMR is much higher in young female patients, a high percentage of patients commit suicide by jumping, and there is a stronger association of long duration of hospitalization and suicide. These factors should be considered in the development and implementation of suicide prevention strategies for Korean psychiatric patients.

Understanding the risks of recent discharge: the phenomenological lived experiences--“existential angst at the prospect of discharge”

BACKGROUND

Evidence indicates that people whose mental health problems lead them to require psychiatric hospitalization are at a significantly increased risk of suicide, and that the time immediately following discharge after such hospitalizations is a particularly high-risk time.

AIMS

This paper reports on phenomenological findings from a federally funded, mixed-methods study that sought to better understand the observed increased risk for suicide following discharge from an inpatient psychiatric service.

METHODS

A purposive sample of 20 recently discharged former suicidal inpatients was obtained. Data were collected in hermeneutic interviews lasting between 1 h and 2 h and analyzed according to van (1997) interpretation of hermeneutic phenomenology.

RESULTS

Two key themes, "existential angst at the prospect of discharge" and "trying to survive while living under the proverbial 'sword of Damocles'" were induced. Each of these was comprised of five themes with the first key theme (which is the focus of this paper) encompassing the following: "Feeling scared, anxious, fearful and/or stressed," "Preparedness," "Leaving the place of safety," "Duality and ambivalence," and "Feel like a burden."

CONCLUSIONS

Early exploration of and reconciling of patients' expectations regarding inpatient care for their suicidality would be empirically based interventions that could diminish the postdischarge risk for further suicide attempts.

Implementation of mental health service recommendations in England and Wales and suicide rates, 1997-2006: a cross-sectional and before-and-after observational study

BACKGROUND

Research investigating which aspects of mental health service provision are most effective in prevention of suicide is scarce. We aimed to examine the uptake of key mental health service recommendations over time and to investigate the association between their implementation and suicide rates.

METHODS

We did a descriptive, cross-sectional, and before-and-after analysis of national suicide data in England and Wales. We collected data for individuals who died by suicide between 1997 and 2006 who were in contact with mental health services in the 12 months before death. Data were obtained as part of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. When denominator data were missing, we used information from the Mental Health Minimum Data Set. We compared suicide rates for services implementing most of the recommendations with those implementing fewer recommendations and examined rates before and after implementation. We stratified results for level of socioeconomic deprivation and size of service provider.

FINDINGS

The average number of recommendations implemented increased from 0·3 per service in 1998 to 7·2 in 2006. Implementation of recommendations was associated with lower suicide rates in both cross-sectional and before-and-after analyses. The provision of 24 h crisis care was associated with the biggest fall in suicide rates: from 11·44 per 10 000 patient contacts per year (95% CI 11·12-11·77) before to 9·32 (8·99-9·67) after (p<0·0001). Local policies on patients with dual diagnosis (10·55; 10·23-10·89 before vs 9·61; 9·18-10·05 after, p=0·0007) and multidisciplinary review after suicide (11·59; 11·31-11·88 before vs 10·48; 10·13-10·84 after, p<0·0001) were also associated with falling rates. Services that did not implement recommendations had little reduction in suicide. The biggest falls in suicide seemed to be in services with the most deprived catchment areas (incidence rate ratio 0·90; 95% CI 0·88-0·92) and the most patients (0·86; 0·84-0·88).

INTERPRETATION

Our findings suggest that aspects of provision of mental health services can affect suicide rates in clinical populations. Investigation of the relation between new initiatives and suicide could help to inform future suicide prevention efforts and improve safety for patients receiving mental health care.

FUNDING

National Patient Safety Agency, UK.

Suicide on the Isle of Wight: A Case-study of 35 Suicides among Mental Health Service Users Between 2006 and 2008

AIMS

To identify the sociodemographic, clinical and service delivery risk factors for suicide in psychiatric patients in a limited geographic area.

METHOD

A retrospective case study of 35 patients who died as a result of suicide between January 2006 and December 2008.

RESULTS

Male gender, unemployment, living alone, basic education and significant life events were identified as sociodemographic factors. A history of previous psychiatric admission, previous suicide attempt, suffering from depression, co-morbidity of another psychiatric disorder (mainly stress-related symptoms and alcoholism), and contacting the services prior to suicide were found as typical clinical factors. Hanging was the most common method of suicide in both men and women. Most men died in spring and summer, while the majority of females died in autumn.

CLINICAL IMPLICATIONS

As in similar studies, mental disorders could be identified as the strongest risk factor for suicide. Almost 70% of suicides were conducted by people suffering from a mental disorder. Treating mental disorders and identifying certain sociodemographic and clinical characteristics of people suffering from mental disorders and addressing them is the key in suicide prevention strategies.

Prospective study of risk factors for increased suicide ideation and behavior following recent discharge

OBJECTIVE

The purpose of this study is to prospectively examine the association between predictors from the three thematic areas - suicidality, personal risk factors and patient care factors - and the occurrence of postdischarge suicide ideation and behavior in recently discharged patients.

METHODS

The design is a prospective cohort study of all patients admitted to an inner city inpatient psychiatric service with a lifetime history of suicidal behavior and current suicidal ideation. Predictors of suicide ideation at 1, 3 and 6 months following discharge and suicide behavior over the 6 months of follow-up were examined.

RESULTS

The incidence of death by suicide during the study period was 3.3% [95% confidence interval (CI)=0.9%-8.3%], and 39.4% (95% CI=30.0%-49.5%) of the surviving participants reported self-injury or suicide attempts within 6 months of hospital discharge. Risk factors such as recent suicide attempts, levels of depression, hopelessness and impulsivity were predictive of increased suicide ideation or behavior after discharge from the inpatient service.

CONCLUSIONS

The high risk of suicide ideation, suicide attempts and suicide demonstrated in these recently discharged patients supports the need to develop selective prevention strategies.

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.

The relationship between the use of Mental Health Act and general population suicide rates in England and Wales

Background:

The relationship between suicide and involuntary admissions has been mainly examined in younger and mixed age groups. These studies provide mixed results with some demonstrating no relationship and others reporting increased rates of suicides in involuntarily admitted patients. However, the association between the utility of the Mental Health Act with general population suicide rates in England and Wales has not been formally studied.

Methods:

Thus, an ecological study, over the 19-year period, to examine the relationship between rates of involuntary admissions and general population suicide rates in England and Wales was undertaken using nationally collected data. Data on general population suicide rates for both sexes were ascertained from the World Health Organization (WHO) website. Data on the number of detentions under the Mental Health Act were ascertained from the Office of National Statistics website. Data on the population size for the elderly age-bands were ascertained from the WHO website. Spearman’s correlation coefficient was used to examine the relationship between suicide rates and rates of detention under the Mental Health Act.

Results:

There were negative correlations between rates of involuntary admissions and general population suicide rates in both sexes.

Conclusions:

A causal relationship and the direction of causality cannot be assumed because this was an ecological study. There is a need for sufficiently powered study to compare the number of suicide occurring in involuntarily and voluntarily admitted patients using a case-control or cohort design and survival analysis. If an inverse association can be demonstrated between suicide and involuntary admissions then it has important implications for the development of mental health legislation as an adjunct to national suicide prevention strategies.

Suicides in psychiatric in-patients: what are we doing wrong?

Given the uncontested role of psychiatric illnesses in both fatal and non-fatal suicidal behaviours, efforts are continuously made in improving mental health care provision. In cases of severe mental disorder, when intensified treatment protocols and continuous supervision are required due to individual's impaired emotional, cognitive and social functioning (including danger to self and others), psychiatric hospitalisation is warranted. However, to date there is no convincing evidence that in-patient care prevents suicide. In fact, quite paradoxically, both admissions to a psychiatric ward and recent discharge from it have been found to increase risk for suicidal behaviours. What elements in the chain of well-intentioned approaches to treating psychiatric illness and suicidality fail to protect this vulnerable population is still unclear. The same holds true for the identifications of factors that may increase the risk for suicide. This editorial discusses current knowledge on this subject, proposing strategies that might improve prevention.

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.