Suicidal behaviour of psychiatric in-patients

OBJECTIVE: The study aimed to examine suicidal behaviour before and during in-patient care in a psychiatric state hospital. METHOD: Based upon a psychiatric basic documentation system prevalence and risk factors of in-patient suicides, suicide attempts and suicidal thoughts were investigated over an 11-year period from 1989 until 1999. RESULTS: A total of 30 in-patient suicides were found among 21 062 patients. According to the multivariate logistic regression analysis the risk of hospital suicide increases for patients with schizophrenia, higher cumulative length of stay, previous suicide attempt, part-time employment and training/retraining. Predictors of suicide attempt during hospitalization are suicide attempt on admission, personality disorder, suicidal thoughts on admission, schizophrenia and affective disorder. CONCLUSION: As Schizophrenics represent the high-risk group of in-patient suicide, suicide prevention should be a major goal in their treatment. More frequent suicide risk assessment is recommended particularly before granting a leave or an outing.     

Suicide among older psychiatric inpatients: an evidence-based study of a high-risk group.

OBJECTIVE: Older adults have elevated suicide rates, especially in the presence of a psychiatric disorder, yet not much is known about predictors for suicide within this high-risk group. The current study examines the characteristics associated with suicide among older adults who are admitted to a psychiatric hospital. METHOD: All persons aged 60 and older living in Denmark who were hospitalized with psychiatric disorders during 1990-2000 were included in the study. Using a case-control design and logistic regression analysis, the authors calculated the suicide risk associated with specific patient characteristics. RESULTS: Affective disorders were found to be associated with an almost twofold higher risk of suicide among psychiatric inpatients than other types of disorders (95% confidence interval [CI]: 1.5-2.6). Patients with dementia had a significantly lower risk ratio of 0.2 (95% CI: 0.1-0.3). In combination with other types of disorder, affective disorders were found to modify an increased risk of suicide. First versus later admission for depression was a better predictor for suicide than age at first hospitalization for depression (before or after age 60 years). More than half of suicides occurred either within the first week of admission or discharge (chi(2) [1] = 27.70, p <0.001) compared with the distribution of patient days. CONCLUSIONS: Our findings underline the important role of affective disorder in combination with other types of disorders. Assessment of suicide risk among older psychiatric inpatients should take current or previous episodes of affective illness into consideration and pay special heed to the time shortly after admission and discharge.     

Modelling suicide risk in affective disorders.

BACKGROUND: The lifetime risk of suicide in affective disorders is commonly quoted as 15%. This stems from hospital populations of affective disorders. AIMS: To model the lifetime prevalence of suicide using data on completed suicides from one English Health District and community-based rates of prevalence of affective disorders. METHODS: A secondary analysis of a primary data set based on 212 suicides in North Staffordshire was undertaken. The population rates of psychiatric morbidity were obtained from the National Comorbidity Survey. RESULTS: The model suggests a lifetime prevalence rate of suicide for any affective disorder at 2.4%, with a rate for those uncomplicated by substance abuse, personality disorder or non-affective psychosis at 2.4%, and a rate for uncomplicated cases who had no mental health service contact at 1.1%. CONCLUSIONS: Lifetime prevalence rates of suicide in subgroups of affective disorders may be lower than the traditional rates cited for hospital depression. This has implications for primary care projects designed to investigate the occurrence of and the prevention of suicide.     

Suicide in subtypes of major affective disorder. A comparison with general population suicide mortality

We investigated the risk of suicide among 705 patients with primary unipolar depression, 302 patients with secondary unipolar depression, and 586 patients with bipolar affective disorder (BAD). The suicide rates among the study subjects were compared with that of the general population of Iowa, the area from which the subjects were selected. An increased risk of suicide was found in all psychiatric groups, except the group of female patients with BAD, which was associated with a lower risk of suicide than unipolar disorders. Thirty suicides (73.2%) occurred during the first two years of follow-up; this trend was particularly pronounced in female patients with primary unipolar depression and male patients with BAD.     

Reductions in postdischarge suicide after deinstitutionalization and decentralization: a nationwide register study in Finland

OBJECTIVE: This study analyzed trends in suicides occurring after a psychiatric hospitalization during more than a decade of significant structural changes in mental health services in Finland-that is, deinstitutionalization, downsizing of inpatient care, and decentralization. METHODS: Retrospective register data on completed suicides and psychiatric inpatient treatments were collected for the periods 1985-1991 and 1995-2001, representing service provision before and after significant structural changes. The data were used to produce an estimate for a change in postdischarge suicide risk. RESULTS: In both periods, a fifth of suicide victims had been psychiatrically hospitalized within the preceding year. Among persons hospitalized, the risk of suicide was greater in 1985-1991 than in 1995-2001 for both one week after discharge (risk ratio [RR]=1.50, 95% confidence interval [CI]=1.38-1.62) and one year after discharge (RR=1.25, CI=1.19-1.30). When types of disorders were analyzed separately, the relative risk of suicide one year postdischarge for those hospitalized in the earlier period was greater for patients with schizophrenia (RR=1.26, CI=1.17-1.36) and patients with affective disorders (RR=1.60, CI=1.48-1.73). In parallel with general development of inpatient psychiatric services, in 1995-2001 the inpatient treatment periods preceding suicides were significantly shorter (a mean+/-SD of 45+/-340 days in 1995-2001, compared with a mean of 98+/-558 days in 1985-1991), the number of individual patients treated in the hospital for schizophrenia spectrum disorders was lower (26% compared with 36%), and the number treated for affective disorders was higher (45% compared with 35%). CONCLUSIONS: The restructuring and downsizing of mental health services was not associated with any increase in suicides immediately (one week) or one year postdischarge. Instead, the risk of these suicides decreased significantly between the two time periods among several diagnostic categories. Although the role of psychiatric hospitalization in general may have changed over time, patients who are hospitalized now may be less suicidal after discharge. Our results indicate, in terms of postdischarge suicides, that the downsizing of psychiatric hospitals has been a success. However, there is still a substantial need for better recognition of suicidal risk among psychiatric patients.     

Psychopharmacological treatment and psychiatric morbidity in 390 cases of suicide with special focus on affective disorders.

OBJECTIVE: The aim of this study was, on the basis of data from health-care registers, to describe the adequacy of psychopharmacological treatment in suicides. METHOD: Data on consecutive suicides in a Danish County (Funen) in the period of 1 April 1991-31 December 1995 were identified in the Danish Psychiatric Central Register, the National Patient Register, the National Health Insurance and Odense University Pharmacoepidemiological Database. RESULTS: Twenty-five per cent of the suicides previously hospitalized due to affective disorders and 3% of the suicides without psychiatric hospitalizations at all, received an apparently adequate treatment with antidepressants the month before suicide. CONCLUSION: The most striking finding was the insufficiency of treatment with antidepressants in the group of suicides without psychiatric hospitalization, in particular in light of the fact that depression is assumed to be present in at least 50% of all suicides.     

Predicting inpatient suicides and suicide attempts by using clinical routine data?

OBJECTIVE: The study aimed at exploring prevalence and risk factors of inpatient suicides and attempted suicides in a psychiatric hospital. METHOD: Based on the German psychiatric basic documentation system, 20,543 patients with 40,451 episodes of inpatient care (1995-2004) in a psychiatric state hospital were included. Besides univariate analyses, multivariate logistic regression analyses and classification and regression tree analyses were performed. RESULTS: Forty-one inpatient suicides were recorded. Risk of inpatient suicide is increased for patients with resistance to psychopharmacological treatment, previous suicide attempt, severe side effects and supportive psychotherapy before admission. Two hundred fourteen inpatient suicide attempts occurred during the 10-year period. Risk factors of inpatient suicide attempt are assault, personality disorder, previous suicide attempt, psychopharmacological treatment resistance, suicidal thoughts at admission, schizophrenia, depression, female sex and length of stay. CONCLUSION: The identified risk factors underline the need for a cautious investigation of previous suicide attempts as well as for giving special attention to patients who have problems with psychopharmacotherapy during hospitalization.     

In-patient suicide in psychiatric hospitals

OBJECTIVE: In-patient suicides continue to be a matter of concern in hospital psychiatry. In-patients at risk for suicide need to be identified. METHOD: In-patient suicides in two psychiatric hospitals were assessed over a time-span of 8 years. Cases were detected by comparing police suicide data with the hospitals' admission and discharge records. Further information was then gathered from patients' records. RESULTS: During the period under investigation 44 in-patients committed suicide, the majority of them being diagnosed with affective disorders (45.4%) or schizophrenia (27.3%). The most commonly used method was 'jumping in front of a vehicle' (34.1%); 79.5% were treated in an open ward at the time of their suicide, 15.9% in a locked unit. The majority of open ward suicides happened outside the hospital; 39.4% of patients had left the ward without giving notice. CONCLUSION: Additional cautionary measures are warranted especially for patients in open wards.     

Psychiatric adolescent inpatients: eight- to ten-year follow-up.

Seventy-seven adolescent psychiatric inpatients, whose index hospitalization was at a mean age of 16, were followed up for eight to ten years after discharge. The important findings at follow-up were as follows. Twelve patients had bipolar affective disorder and were severely disabled (of these, 11 had a long-term clinical course and three committed suicide). Sixteen patients had unipolar depression: five had one depressive episode and were well throughout the follow-up period, one patient had many episodes with complete remissions, and the remaining ten patients had only partial remissions and their impairment of functioning corresponded to the severity of their symptoms. One of the ten committed suicide. Eighteen (23%) patients were psychiatrically well and functioned adequately throughout the follow-up period. Five had primary depressions, five had undiagnosed psychiatric illness, and eight were diagnosed as not having a psychiatric disorder.     

Excess suicide among formerly hospitalized child psychiatry patients

The authors report suicide risk among 1331 child psychiatry inpatients followed up for 4 to 15 years in a record-linkage study. Age- and sex-matched comparisons were made with the general population of Iowa (the state from which most of the subjects were selected). Suicide rates were higher than expected for both sexes, but the excess (9 suicides) was significant only for males. No suicides occurred earlier than age 17. The risk of suicide was 80 times that expected for schizophrenic patients and 25 times that expected for patients with organic mental disorders. Unlike follow-up studies of adult inpatients, a significant excess of suicide was not associated with affective disorder, substance abuse, neurosis, or anorexia nervosa. Clinical variables indicating more complicated psychiatric disturbance were associated with an even greater rate of suicide; these variables included multiple hospitalizations, a hospital stay of more than 15 days, and the presence of a medical diagnosis.     

A study of suicide in state mental hospitals in New York city

Suicides at five state hospitals for the mentally-ill located in NYC were studied over a 32 month period. The suicide rates at the individual hospitals appeared to be primarily related to the acuteness of inpatient population and secondarily to the socioeconomic-ethnic characteristics of the inpatient population. White young Puerto Rican male, better educated female involuntarily committed, schizophrenic, and affective disordered patients were overrepresented in the suicide group; black patients were underrepresented. From clinical data two profiles of psychiatric inpatients at high risk for suicide were constructed; 1) a male paranoid schizophrenic with previous suicide attempts involuntarily committed due to acute psychosis who hangs himself in his room or bathroom during the first weeks of hospitalization; 2) a chronic undifferentiated schizophrenic often with affective component who has been hospitalized for more than one month and who is considered by staff to be improving, but is having difficulty with discharge planning who commits suicide by jumping while out of the hospital on an authorized pass. Recommendations were made for reducing inpatient suicides.     

Suicide attempts, platelet monoamine oxidase and the average evoked response.

The relationship between suicides and suicide attempts and two biological measures, platelet monoamine oxidase levels (MAO) and average evoked response (AER) augmenting, was examined in 79 off-medication psychiatric patients and in 68 college student volunteers chosen from the upper and lower deciles of MAO activity levels. In the patient sample, male individuals with low MAO and AER augmenting, a pattern previously associated with bipolar affective disorders, showed a significantly increased incidence of suicide attempts in comparison with either non-augmenting low MAO or high MAO patients. Within the normal volunteer group, all male low MAO probands with a family history of suicide or suicide attempts were AER augmenters themselves. Four completed suicides were found among relatives of low MAO probands where as no high MAO proband had a relative who committed suicide. These findings suggest that the combination of low platelet MAO activity and AER augmenting may be associated with a possible genetic vulnerability to psychiatric disorders.     

The relationship of restrictions on state hospitalization and suicides among emergency psychiatric patients

OBJECTIVE: This study explored the relationship between mandated decreases in transfers to a state hospital from a large urban psychiatric emergency facility and the occurrence of suicide in the catchment area served. METHODS: During 1996, new admission criteria that emphasized psychiatric diagnosis and potential benefit from hospitalization and that restricted the admission of recidivistic patients and of those with a primary diagnosis of a substance use disorder were phased in. Data on the number of patients seen in a psychiatric emergency service and the number transferred to the state hospital were obtained for the period 1994-1998. Data on all completed suicides in the county served by the hospital were also obtained. RESULTS: During 1994 and 1995, a total of 9,308 patients were transferred to the state hospital. In 1997 and 1998, a total of 4,072 patients were transferred. The number of patients seen in the emergency service remained constant throughout the study period. No change was noted in the absolute number or the rate of suicide in the county after the new admission criteria were implemented. A total of 164 suicides were recorded in 1994-1995 (12 per 100,000 population per year), compared with 152 in 1997-1998 (ten per 100,000 population per year). CONCLUSIONS: Transfers to the state hospital were reduced by 56 percent, with no change in the suicide rate. This finding suggests that the availability of inpatient psychiatric hospitalization may not have a direct effect on the suicide rate.     

Risk factors for adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients

The characteristics of adolescent suicide victims (n = 27) were compared with those of a group at high risk for suicide, suicidal psychiatric inpatients (n = 56) who had either seriously considered (n = 18) or actually attempted (n = 38) suicide. The suicide victims and suicidal inpatients showed similarly high rates of affective disorder and family histories of affective disorder, antisocial disorder, and suicide, suggesting that among adolescents there is a continuum of suicidality from ideation to completion. However, four putative risk factors were more prevalent among the suicide victims: (1) diagnosis of bipolar disorder; (2) affective disorder with comorbidity; (3) lack of previous mental health treatment; and (4) availability of firearms in the homes, which taken together accurately classified 81.9% of cases. In addition, suicide completers showed higher suicidal intent than did suicide attempters. These findings suggest a profile of psychiatric patients at high risk for suicide, and the proper identification and treatment of such patients may prevent suicide in high-risk clinical populations.     

Suicide rates in the Lundby cohort before and after the introduction of tricyclic antidepressant drugs.

The Lundby cohort consisting of 3563 subjects was investigated in 1947, 1957, 1972, and 1997. It represents a rural, but gradually urbanized Swedish sample without non-Nordic immigrants and offers an opportunity to study suicide rates before and after the introduction of tricyclic antidepressant drugs in Sweden in 1962. Since then, a fall in suicide rate among depressed individuals was observed, while there was an increase in the overall suicide rate. In fact, in 1977-1992 other psychiatric diagnoses, alcohol disorder included, were more often associated with suicide than depression. No psychiatric or alcohol disorder was registered in 7% of the suicides.     

Suicide in psychiatric patients in Denmark, 1971-1981. II. Hospital utilization and risk groups

A register-based analysis was made of hospital utilization and time of suicide among psychiatric patients in Denmark. Suicidal schizophrenic patients had long hospitalizations and their suicide frequency was comparatively constant. Patients with reactive psychoses and affective reactions had more often only one hospitalization and few bed/days. Forty percent of the latter group had previously attempted suicide and only one in six was offered outpatient follow-up. The highest age-, sex-, and diagnosis-specific suicide rates were found among middle-aged and elderly men with manic-depressive or reactive psychoses, and neuroses or personality disorders. Some groups of patients with affective reactions had comparatively high suicide rates, whereas those for patients with a main diagnosis of substance abuse corresponded to the average for the whole patient population. The average suicide rates for manic-depressive women corresponded to that for all male patients.     

Survival time after last hospitalization among suicide victims in northern Finland

Psychiatric patients exhibit increased suicide risk shortly after hospitalization, but little is known about patients who are discharged after treatment for physical illness. Information on all suicides over a period of 13 years in northern Finland as well as information from hospital registers were used to examine the interval between the last hospitalization and the suicide. On the basis of discharge diagnoses of physical or psychiatric illnesses, three groups were distinguished. Among victims with psychiatric disorders, survival time was shorter than among those without such a history, even if the last admission was for a physical condition. Clinicians should note the putative suicide risk among somatic patients at discharge, especially among those with a psychiatric history.