Increase in US Suicide Rates and the Critical Decline in Psychiatric Beds

Reducing Physical Restraint Use in the Medical Behavioral Unit

OBJECTIVES

Children with behavioral health conditions often experience agitation when admitted to children's hospitals. Physical restraint should be used only as a last resort for patient agitation because it endangers the physical and psychological safety of patients and employees. At the medical behavioral unit (MBU) in our children's hospital, we aimed to decrease the weekly rate of physical restraint events per 100 MBU patient-days, independent of patient race, ethnicity, or language, from a baseline mean of 14.0 to <10 within 12 months.

METHODS

Using quality improvement methodology, a multidisciplinary team designed, tested, and implemented interventions including a series of daily deescalation huddles led by a charge behavioral health clinician that facilitated individualized planning for MBU patients with the highest behavioral acuity. We tracked the weekly number of physical restraint events per 100 MBU patient-days as a primary outcome measure, weekly physical restraint event duration as a secondary outcome measure, and MBU employee injuries as a balancing measure.

RESULTS

Our cohort included 527 consecutive patients hospitalized in the MBU between January 2021 and January 2023. Our 2021 baseline mean of 14.0 weekly physical restraint events per 100 MBU patient-days decreased to 10.0 during our 2022 intervention period from January through July and 4.1 in August, which was sustained through December. Weekly physical restraint event duration also decreased from 112 to 67 minutes without a change in employee injuries.

CONCLUSIONS

Multidisciplinary huddles that facilitated daily deescalation planning safely reduced the frequency and duration of physical restraint events in the MBU.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) visits of children and youth to emergency departments are increasing in the United States. Reasons for these visits range from suicidal ideation, self-harm, and eating and substance use disorders to behavioral outbursts, aggression, and psychosis. Despite the increase in prevalence of these conditions, the capacity of the health care system to screen, diagnose, and manage these patients continues to decline. Several social determinants also contribute to great disparities in child and adolescent (youth) health, which affect MBH outcomes. In addition, resources and space for emergency physicians, physician assistants, nurse practitioners, and prehospital practitioners to manage these patients remain limited and inconsistent throughout the United States, as is financial compensation and payment for such services. This technical report discusses the role of physicians, physician assistants, and nurse practitioners, and provides guidance for the management of acute MBH emergencies in children and youth. Unintentional ingestions and substance use disorder are not within the scope of this report and are not specifically discussed.

Reducing physical restraints in pediatrics: A quality improvement mixed-methods analysis of implementing a clinical debriefing process after behavioural health emergencies in a Children's Hospital

INTRODUCTION

An increasing number of pediatric patients with mental and behavioral health (MBH) conditions present to Emergency Department (ED) and inpatient settings with behavioral events that require physical restraint (PR). PR usage is associated with adverse outcomes. Clinical debriefing (CD) programs have been associated with improved performance but have not been studied in this population. After implementing an MBH-CD program in our Children's Hospital, we aimed to decrease the baseline (7/2018-3/2021) rate of a second PR episode (2PR) by 50 % in the ED and inpatient settings over two years.

METHODS

A multidisciplinary team implemented an MBH-CD process in April 2021 for hospital teams to use immediately after behavioral events. We included patients ≤18 years old, with an ED or inpatient discharge MBH diagnosis, between July 2018 and June 2023. Pre- and post-implementation secondary outcomes included the ED median duration of PR and the ED PR time per 1000 h of ED care. ED and inpatient mean length of stay (LOS) and mean monthly visits (MMV) in pre- and post-implementation were also compared. Qualitative analysis identified major themes.

RESULTS

Post-implementation, the ED significantly decreased 2PR rate by 67 %; in inpatients, no significant change was demonstrated. Median duration of ED PR decreased from 112 to 71 min (p = 0.006) and ED PR time significantly decreased by 82 % (14.8 to 2.7 h per 1000 h). In the post-implementation period, mean LOS (ED and inpatient) and MMV (ED only) were significantly higher. Fifty-one percent of 494 behavioral alerts were debriefed. Median debriefing duration was 6 min (IQR 4,10). Common themes included cooperation and coordination (23 %) and clinical standards (14 %).

DISCUSSION

Clinical debriefing implementation was associated with significant improvement in ED patient outcomes. Inpatient outcomes were unchanged, but debriefings in both settings should enable frontline teams to continuously identify opportunities to improve future outcomes.

When to discharge and when to voluntary or compulsory hospitalize? Factors associated with treatment decision after self-harm

Clinicians assessing suicidal patients in emergency departments (EDs) must decide whether to admit the person to a psychiatric ward with voluntary or compulsory hospitalization or to discharge him/her as an outpatient. This cross-sectional study aimed to identify independent predictors of this decision among a large sample of self-harm (SH) patients. It used data from all patients admitted to four Swiss EDs between 2016 and 2019. Socio-demographic, clinical, and suicidal process-related characteristics data were evaluated against the decision for voluntary or compulsory hospitalization using t-tests, Chi-Square tests and logistic multiple regression. 2142 episodes from 1832 unique patients were evaluated. Independent predictors of decision to hospitalize included: male gender, advanced age, hospital location, depression and personality disorders, substance use, a difficult socio-economic condition, a clear intent to die, and a serious suicide attempt. Significant variables that emerged as independent predictors of compulsory hospitalization were hospital location, not having anxiety and personality disorders, being retired, having a clear intent to die, and making a serious suicide attempt. Hospital EDs had different rates of compulsory psychiatric admission. However, the decision to admit a patient for hospitalization, either voluntary or compulsory, was mainly based on clinical factors.

Achieving health equity in US suicides: a narrative review and commentary

Suicide rates in the United States (US) reached a peak in 2018 and declined in 2019 and 2020, with substantial and often growing disparities by age, sex, race/ethnicity, geography, veteran status, sexual minority status, socioeconomic status, and method employed (means disparity). In this narrative review and commentary, we highlight these many disparities in US suicide deaths, then examine the possible causes and potential solutions, with the overarching goal of reducing suicide death disparities to achieve health equity.

The data implicate untreated, undertreated, or unidentified depression or other mental illness, and access to firearms, as two modifiable risk factors for suicide across all groups. The data also reveal firearm suicides increasing sharply and linearly with increasing county rurality, while suicide rates by falls (e.g., from tall structures) decrease linearly by increasing rurality, and suicide rates by other means remain fairly constant regardless of relative county urbanization. In addition, for all geographies, gun suicides are significantly higher in males than females, and highest in ages 51–85 + years old for both sexes. Of all US suicides from 1999–2019, 55% of male suicides and 29% of female suicides were by gun in metropolitan (metro) areas, versus 65% (Male) and 42% (Female) suicides by gun in non-metro areas. Guns accounted for 89% of suicides in non-metro males aged 71–85 + years old. Guns (i.e., employment of more lethal means) are also thought to be a major reason why males have, on average, 2–4 times higher suicide rates than women, despite having only 1/4—1/2 as many suicide attempts as women. Overall the literature and data strongly implicate firearm access as a risk factor for suicide across all populations, and even more so for male, rural, and older populations.

To achieve the most significant results in suicide prevention across all groups, we need 1) more emphasis on policies and universal programs to reduce suicidal behaviors, and 2) enhanced population-based strategies for ameliorating the two most prominent modifiable targets for suicide prevention: depression and firearms.

Why did China's mental health law have a limited effect on decreasing rates of involuntary hospitalization?

BACKGROUND

China's Mental Health Law (MHL) implemented in 2013 required increased consideration of the rights of people with mental illness and was expected to lead to a reduction in involuntary hospitalization (IH). This study aimed to examine the rates and correlates of IH in a large psychiatric hospital in Guangzhou from 2014 to 2017 after the implementation of MHL and a structured assessment of the need for IH.

METHODS

Unduplicated electronic medical records concerning all inpatients admitted to the hospital with a primary psychiatric diagnose were examined. Diagnostic, sociodemographic and socioeconomic data were used to identify correlates of IH using bivariate chi-square tests followed by logistic regression analysis.

RESULTS

Of 10, 818 hospitalized patients, there was a significant but small increase, from 71.6 to 74.9% in rates of IH in the years after a structured assessment of need for IH was implemented. Logistic regression analysis showed IH was positively associated with being younger, having a local residence, and a diagnosis of bipolar disorder, schizophrenia spectrum disorders or a substance abuse disorder as compared to those diagnosed with major depressive disorder.

CONCLUSIONS

IH did not decrease over the first four years after the implementation of China's MHL and a structured assessment in 2013 perhaps, reflecting the initiation of a systematic assessment of the need for IH and the relatively low number of psychiatric beds in this area.

Pharmacist impact on medication reconciliation of behavioral health patients boarding in the emergency department

Introduction

The high demand for psychiatric services has exceeded the capacity of available resources for behavioral health patients, forcing these patients to seek mental health care in the emergency department. Average lengths of stay for behavioral health boarders commonly extend over multiple days and prior-to-admission (PTA) medication administration may be delayed, which could lead to further deterioration and longer inpatient lengths of stay. Addition of a pharmacist-led medication reconciliation process and pharmacist integration into daily emergency department psychiatry rounds may decrease time to initiation of PTA medications and improve outcomes in this population.

Methods

This is a retrospective review of adult patients who required a psychiatric emergency evaluation in a large rural academic medical center emergency department. Objectives were to determine the number and type of medication discrepancies found with pharmacist intervention, and to compare time to initiation of PTA medications with a pharmacist versus a nonpharmacist completing medication reconciliation.

Results

A total of 139 patients were identified, 85 patients in August 2019 (no pharmacist [NP]) and 54 in October 2019 (pharmacist involvement [PI]). Among 484 medications reviewed in the PI group, 298 discrepancies were identified. The most common types of discrepancies were no longer taking (n = 99, 33%) and omission (n = 94, 32%). Time to administration of PTA medications was similar between NP and PI groups (median hours, interquartile range: NP: 10.8, 7.8-16.57; PI: 11.49, 6.16-16; P = .179).

Discussion

This study depicted one of the many values of pharmacists in the hospital setting, especially in the behavioral health patient population where continuation of accurate PTA medications may prevent further clinical deterioration.

Psychiatric beds and prison populations in 17 Latin American countries between 1991 and 2017: rates, trends and an inverse relationship between the two indicators

BACKGROUND

In 1990, Latin American countries committed to psychiatric reforms including psychiatric bed removals. Aim of the study was to quantify changes in psychiatric bed numbers and prison population rates after the initiation of psychiatric reforms in Latin America.

METHODS

We searched primary sources to collect numbers of psychiatric beds and prison population rates across Latin America between the years 1991 and 2017. Changes of psychiatric bed numbers were compared against trends of incarceration rates and tested for associations using fixed-effects regression of panel data. Economic variables were used as covariates. Reliable data were obtained from 17 Latin American countries: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, Honduras, Guatemala, Mexico, Nicaragua, Panama, Paraguay, Peru, El Salvador, Uruguay and Venezuela.

RESULTS

The number of psychiatric beds decreased in 15 out of 17 Latin American countries (median -35%) since 1991. Our findings indicate the total removal of 69 415 psychiatric beds. The prison population increased in all countries (median +181%). Panel data regression analyses showed a significant inverse relationship -2.70 (95% CI -4.28 to -1.11; p = 0.002) indicating that prison populations increased more when and where more psychiatric beds were removed. This relationship held up when introducing per capita income and income inequality as covariates -2.37 (95% CI -3.95 to -0.8; p = 0.006).

CONCLUSIONS

Important numbers of psychiatric beds have been removed in Latin America. Removals of psychiatric beds were related to increasing incarceration rates. Minimum numbers of psychiatric beds need to be defined and addressed in national policies.

Suicide Risk Among Hospitalized Versus Discharged Deliberate Self-Harm Patients: Generalized Random Forest Analysis Using a Large Claims Data Set

INTRODUCTION

Suicide rates are extremely high among emergency department patients seen for deliberate self-harm. Inpatient hospitalization is often recommended for these patients, but evidence on the suicide prevention impacts of hospitalization is scarce. Confounding by indication and challenges to implementing randomized designs are barriers to advances in this field.

METHODS

Investigators used 2009-2012 statewide data on 57,312 self-harm emergency department patients from California, linked to mortality records. Naive 12-month and 30-day suicide risks were estimated among patients who were hospitalized versus those who were discharged. Then, generalized random forest methods were applied to estimate the average treatment impacts of hospitalization on suicide, conditioning on observable covariates. Associations were calculated separately for sex- and age-specific subgroups. Analyses were conducted in February 2019-August 2021.

RESULTS

In naive analyses, suicide risk was significantly higher in hospitalized than in discharged patients in each subgroup. In 12-month models accounting for the observed covariates through generalized random forest methods, hospitalized male patients had 5.4 more suicides per 1,000 patients (95% CI=3.0, 7.8), hospitalized patients aged 10-29 years had 2.4 more suicides per 1,000 (95% CI=1.1, 3.6), and those aged ≥50 years had 5.8 more suicides per 1,000 (95% CI=0.5, 11.2) than corresponding discharged patients. Hospitalization was not significantly associated with suicide among female patients or patients aged 30-49 years in generalized random forest analyses. Patterns were similar in 30-day generalized random forest models.

CONCLUSIONS

Emergency department personnel intend to hospitalize self-harm patients with high suicide risk; this study suggests that this goal is largely realized. Analyses that control for confounding by observable covariates did not find clear evidence that hospitalization reduces suicide risk and could not rule out the possibility of iatrogenic effects.

The effects of national mental health plans on mental health services development in Chile: retrospective interrupted time series analyses of national databases between 1990 and 2017

AIMS

To describe changes in mental health services in Chile between 1990 and 2017, and to retrospectively assess the effects of national mental health plans (NMHPs) on mental health services development during this period.

METHODS

Service data (beds in psychiatric hospitals, psychiatric beds in general hospitals, forensic psychiatric beds, beds in protected housing facilities, psychiatric day hospital places, and outpatient mental health care centers) were retrieved from government sources in Chile. Data were reported as rates per 100,000 population. We conducted interrupted time series analyses, using ordinary least-square regressions with Newey-West standard errors, to assess the effects of the 1993 and 2000 NMPHs on mental health services development.

RESULTS

Rates of short- and long-stay beds in psychiatric hospitals (per 100,000 population) were reduced from 4.3 to 3.2 and from 19.0 to 2.0 over the entire time span, respectively. The strongest reduction of short- and long-stay beds in psychiatric hospitals was seen between the 1993 and 2000 NMHPs (annual removal of - 0.14 and - 1.03, respectively). We observed increased rates of psychiatric beds in general hospitals from 1.8 to 4.0, beds in protected housing facilities from 0.4 to 10.2, psychiatric day hospital places from 0.4 to 5.0, outpatient mental health care centers from 0.1 to 0.8 and forensic psychiatric beds from 0.3 to 1.1 over the entire time span. The strongest annual increase of rates of psychiatric beds in general hospitals (0.09), beds in protected housing facilities (0.50), psychiatric day hospital places (0.16) and outpatient mental health care centers (0.04) were observed after the 2000 NMHP. Forensic psychiatric beds increased in the year 2007 (0.58) due to the opening of a new facility.

CONCLUSIONS

The majority of acute care psychiatric beds in Chile now are based in general hospitals. The strong removal of short- and long-stay beds from psychiatric hospitals after the 1993 NMHP preceded substantial expansion of more modern mental health services in general hospitals and in the community. Only after the 2000 NMHP, the implementation of new mental health services gained momentum. Reiterative policies are needed to readjust mental health services development.

Characteristics of Korean students advised to seek psychiatric treatment before death by suicide

INTRODUCTION

Suicide is the leading cause of death among adolescents in Korea. Psychiatric disorders are well-known risk factors for suicide, but the proportion of children and adolescents who died by suicide and who had received psychiatric treatment is low. This study aims to examine how many school students who died by suicide were advised by their school to seek psychiatric treatment before their death and to characterize their clinical characteristics.

METHODS

We analyzed data collected by the Ministry of Education of Korea for all students who died by suicide between 2016 and 2020. Students were grouped according to whether or not they were advised to seek psychiatric treatment by their school-based on mental health screening and teachers' judgments. Sociodemographic characteristics (sex, educational stage, family structure, and socioeconomic status), suicide-related characteristics (place of suicide, suicide method, suicide note, previous self-harm, and previous suicide attempt), emotional and behavioral status, school life and personal, and family problems were compared between the two groups.

RESULTS

Analysis was conducted for 544 students, 110 (20.2%) of whom were advised to seek psychiatric treatment by their school before their death. This group had a higher proportion of girls; poorer attendance; higher frequency of depression, anxiety, impulsivity, and social problems; personal problems (appearance, friend-related, and mental and physical health problems); family problems (mental health problems of family, bad relationship with parents, and conflict of parents); and higher incidence of self-harm or suicide attempts (P < 0.001) than the other group.

CONCLUSION

Teachers seem to advise psychiatric treatment when mental health problems are revealed at school. It showed distinctive clinical characteristics between the two groups. Preventing suicide among students requires the attention and effort not only of schools, but also of families, communities, and mental health professionals.

Association between acute psychiatric bed availability in the Veterans Health Administration and veteran suicide risk: a retrospective cohort study

BACKGROUND

Veteran suicides have increased despite mental health investments by the Veterans Health Administration (VHA).

OBJECTIVE

To examine relationships between suicide and acute inpatient psychiatric bed occupancy and other community, hospital and patient factors.

METHODS

Retrospective cohort study using administrative and publicly available data for contextual community factors. The study sample included all veterans enrolled in VHA primary care in 2011-2016 associated with 111 VHA hospitals with acute inpatient psychiatric units. Acute psychiatric bed occupancy, as a measure of access to care, was the main exposure of interest and was categorised by quarter as per cent occupied using thresholds of ≤85%, 85.1%-90%, 90.1%-95% and >95%. Hospital-level analyses were conducted using generalised linear mixed models with random intercepts for hospital, modelling number of suicides by quarter with a negative binomial distribution.

RESULTS

From 2011 to 2016, the national incidence of suicide among enrolled veterans increased from 39.7 to 41.6 per 100 000 person-years. VHA psychiatric bed occupancy decreased from a mean of 68.2% (IQR 56.5%-82.2%) to 65.4% (IQR 53.9%-79.9%). VHA hospitals with the highest occupancy (>95%) in a quarter compared with ≤85% had an adjusted incident rate ratio (IRR) for suicide of 1.10 (95% CI 1.01 to 1.19); no increased risk was observed for 85.1%-90% (IRR 0.96; 95% CI 0.89 to 1.03) or 90.1%-95% (IRR 0.96; 95% CI 0.89 to 1.04) compared with ≤85% occupancy. Of hospital and community variables, suicide risk was not associated with number of VHA or non-VHA psychiatric beds or amount spent on community mental health. Suicide risk increased by age categories, seasons, geographic regions and over time.

CONCLUSIONS

High VHA hospital occupancy (>95%) was associated with a 10% increased suicide risk for veterans whereas absolute number of beds was not, suggesting occupancy is an important access measure. Future work should clarify optimal bed occupancy to meet acute psychiatric needs and ensure adequate bed distribution.

A Critique on Psychiatric Inpatient Admissions for Suicidality in Youth

ABSTRACT

For the last few decades, psychiatric inpatient admissions for the treatment of suicidality in US youth have been increasing. Nonetheless, since 2007, the national rate of completed suicides by youth has steadily and sizably increased. Therefore, a literature review was performed to evaluate the usefulness of the psychiatric inpatient admission of suicidal youths. The analysis concluded that suicidality is surprisingly common in youth, completed suicide is very uncommon in early adolescence, suicidal ideation is a major reason in early adolescence for inpatient admission, girls are admitted to psychiatric inpatient units three times more than boys even though boys complete suicide four times more than girls, inpatient stays average 6 days and are quite expensive, and repeat attempts after inpatient treatment are common. Thus, filling more beds for youth with suicidality lacks evidence of a public health, long-term benefit. Expanding the focus in psychiatry to population efforts including means reductions is recommended.

Treating Pediatric and Geriatric Patients at Risk of Suicide in General Emergency Departments: Perspectives From Emergency Department Clinical Leaders

STUDY OBJECTIVE

We explored emergency department clinical leaders' views on providing emergency mental health services to pediatric and geriatric patients with suicidal ideation and suicide attempts.

METHODS

We conducted semistructured interviews with a total of 34 nursing directors, medical directors, and behavioral health managers at 17 general hospital EDs across the United States, using purposive sampling to ensure variation among hospitals. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using Atlas.ti and a directed content analysis approach.

RESULTS

Respondents from across a range of ED types expressed concerns regarding the capacity of their EDs to meet mental health needs of children and older adults. They experienced emotional distress over the increasing number of pediatric patients presenting to EDs with suicidal ideation/suicide attempt and described EDs as inappropriate environments for young patients with suicidal ideation/suicide attempt. Similarly, leaders expressed feeling ill-equipped to diagnose and treat geriatric patients with suicidal ideation/suicide attempt, who often had medical comorbidities that complicated treatment planning. Respondents noted that pediatric and geriatric patients frequently boarded in the ED. Some felt compelled to use creative solutions to provide safe spaces for pediatric and geriatric patients. Respondents voiced frustration over the lack of outpatient and inpatient mental health services for these patients.

CONCLUSION

Clinical leaders in EDs across the nation expressed distress at feeling they were not adequately equipped to meet the needs of pediatric and geriatric patients with suicidal ideation/suicide attempt. Future innovations to provide ED care for children and older adults with suicidal ideation/suicide attempt might include training for ED teams, access to specialist mental health clinicians through telehealth, and adaptations of physical spaces.

Rising Clinical Burden of Psychiatric Visits on the Pediatric Emergency Department

OBJECTIVE

The mental health epidemic in pediatrics has resulted in a growing clinical burden on the health care system, including pediatric emergency departments (PED). Our objective was to describe the changing characteristics of visits to an urban PED, in particular length of stay, for emergency psychiatric evaluations (EPEs) over a 10-year period.

METHODS

A retrospective study of children with an EPE in the PED at a large urban quaternary care children's hospital was performed during two discrete periods a decade apart: July 1, 2003-June 30, 2004 (period 1) and July 1, 2013-June 30, 2014 (period 2). Visit information, including length of stay and demographic data, were compared between groups.

RESULTS

There was a significant increase in the percentage of PED visits for EPE from period 1 to period 2 (1.1% vs 2.2% P < 0.0001). Overall, the median (interquartile range [IQR]) length of stay for children requiring an EPE increased significantly for all visits (5.3 [3.2-15.4] hours vs 17.0 [6.0-26.0] hours, P < 0.0001), including for patients who were admitted (17.8 [7.4-24.6] hours vs 27.0 [21.0-36.0] hours, P < 0.0001) and for those who were discharged (4.5 [2.8-7.7] hours vs 8 [5-20] hours, P < 0.0001).

CONCLUSIONS

Over a decade, the percentage of children with an EPE has doubled, with a significant increase in the amount of time spent in the PED. This highlights a continued surge in the utilization of PED resources for EPE.

Observed Outcomes: An Approach to Calculate the Optimum Number of Psychiatric Beds

The number of psychiatric beds, in most developed countries, has decreased progressively since the late 1950s. Many clinicians believe that this reduction has gone too far. But how can we determine the number of psychiatric beds a mental health system needs? While the population health approach has advantages over the normative approach, it makes assumptions about optimal and minimum duration of hospitalization required for various psychiatric disorders. In this paper, we describe a naturalistic approach that estimates the required number of psychiatric beds by comparing the bed levels at which negative outcomes develop in different jurisdictions. We hypothesize that there will be a threshold below which negative outcomes will be seen across jurisdictions. We predict that hospital key performance indices will be more sensitive to bed reductions than the clinical and social outcomes of patients. The observed outcome approach can complement other approaches to determining bed numbers at the national and local levels, and should be a priority for future health services research.

Changes in community mental health services availability and suicide mortality in the US: a retrospective study

BACKGROUND

Despite the fact that the overwhelming majority of mental health services are delivered in outpatient settings, the effect of changes in non-hospital-based mental health care on increased suicide rates is largely unknown. This study examines the association between changes in community mental health center (CMHC) supply and suicide mortality in the United States.

METHODS

Retrospective analysis was performed using data from National Mental Health Services Survey (N-MHSS) and the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) (2014-2017). Population-weighted multiple linear regressions were used to examine within-state associations between CMHCs per capita and suicide mortality. Models controlled for state-level characteristics (i.e., number of hospital psychiatric units per capita, number of mental health professionals per capita, age, race, and percent low-income), year and state.

RESULTS

From 2014 to 2017, the number of CMHCs decreased by 14% nationally (from 3406 to 2920). Suicide increased by 9.7% (from 15.4 to 16.9 per 100,000) in the same time period. We find a small but negative association between the number of CMHCs and suicide deaths (- 0.52, 95% CI - 1.08 to 0.03; p = 0.066). Declines in the number of CMHCs from 2014 to 2017 may be associated with approximately 6% of the national increase in suicide, representing 263 additional suicide deaths.

CONCLUSIONS

State governments should avoid the declining number of CMHCs and the services these facilities provide, which may be an important component of suicide prevention efforts.

A longitudinal description of incompetent to stand trial admissions to a state hospital

OBJECTIVE

Evidence is clear that the nation is experiencing an increasing number of incompetent to stand trial (IST) admissions to state hospitals. As a result, defendants in need of treatment can wait in jail for weeks for admission for restoration. This study was conducted to better understand this growing population and to inform hospital administration about the characteristics of IST admissions.

METHODS

The study was conducted at the Department of State Hospitals (DSH) facility in Napa (DSH-Napa), a 1200-bed primarily forensic inpatient psychiatric facility located in northern California. The records of patients found IST and admitted to DSH-Napa for restoration of competence between the dates of 1/1/2009 and 12/31/2016 were eligible for inclusion in the study.

RESULTS

There were a total of 3158 unduplicated IST admissions available during the specified time period. Our data indicate that the number of admissions with more than 15 prior arrests increased significantly, from 17.7% in 2009 to 46.4% in 2016. In contrast, the percent of patients reporting prior inpatient psychiatric hospitalization evidenced a consistent decrease over time from over 76% in 2009 to less than 50% in 2016.

CONCLUSION

Our data add to the body of literature on the potential causes of the nationwide increase in competency referrals. The literature is clear that jails and prisons are now the primary provider of the nation's mental health care. Our data suggest that another system has assumed this role: state hospitals and other providers charged with restoring individuals to competence.

A survey of national trends in psychiatric patients found incompetent to stand trial: reasons for the reinstitutionalization of people with serious mental illness in the United States

OBJECTIVE

Recent information indicates that the number of forensic patients in state hospitals has been increasing, largely driven by an increase in patients referred to state hospitals as incompetent to stand trial (IST). This survey was intended to broaden the understanding of IST population trends on a national level.

METHODS

The authors developed a 30-question survey to gather specific information on IST commitments in each state and the District of Columbia. The survey was administered to all 50 states and the District of Columbia via email. Specific individuals identified as primary administrators responsible for the care and evaluation of IST admissions in each state were contacted.

RESULTS

A total of 50 out of the 51 jurisdictions contacted completed the survey. Fully 82% of states indicated that referrals for competency evaluation were increasing. Additionally, 78% of respondents thought referrals for competency restoration were increasing. When asked to rank factors that led to an increase, the highest ranked response was inadequate general mental health services in the community. Inadequate crisis services were the second ranked reason. Inadequate number of inpatient psychiatric beds in the community was the third highest, with inadequate assertive community treatment services ranking fourth.

CONCLUSIONS

Understanding the national trend and causes behind the recent surge in referrals for IST admissions will benefit states searching for ways to remedy this crisis. Our survey indicates most states are facing this issue, and that it is largely related to insufficient services in the community.

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

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

National trends in mental health-related emergency department visits by children and adults, 2009-2015

OBJECTIVES

Examine trends in mental health-related emergency department (ED) visits, changes in disposition and length of stay (LOS), describe disposition by age and estimate proportion of ED treatment hours dedicated to mental health-related visits.

METHODS

Retrospective analysis of ED encounters in the National Hospital Ambulatory Medical Care Visit Survey with a mental health primary, secondary or tertiary discharge diagnosis from 2009 to 2015. We report survey-weighted estimates of the number and proportion of ED visits that were mental health-related and disposition by age and survey year. We estimate the proportion of ED treatment hours dedicated to mental health-related visits. We analyze trends in disposition and LOS for mental health and non-mental health-related visits using multivariate regression analysis.

RESULTS

Mental health-related ED visits increased by 56.4% for pediatric patients and 40.8% for adults, accounting for over 10% of ED visits by 15-64 year-olds and nearly 9% by 10-14 year-olds in 2015. Mental health-related visit disposition of admission or transfer declined from 29.8% to 20.4% (p < .001); predicted median ED LOS for admissions or transfers increased from 6.5 to 9.0 hours while median LOS for discharges was stable at 4.4 hours. During the study period, mental health-related visits accounted for 5.0% (95% CI 4.6-5.3) of all pediatric and 11.1% (95% CI 11.0-11.3) of adult ED treatment hours.

CONCLUSIONS

Mental health-related visits account for an increasing proportion of ED visits and a considerable proportion of treatment hours. A decreasing proportion of mental health-related visits resulted in inpatient disposition and ED LOS increased for admissions and transfers.

Epidemiology of suicide: recent developments

Suicide and suicide attempts have become more prevalent in recent years, with notable increases in the US in all age groups and geographic locations. Risk of suicide is particularly high among patients diagnosed with bipolar disorder or severe depression, especially when associated with mixed features or agitation, or with co-occurring substance abuse. Factors contributing to such risk include relative social and geographic isolation and low access to sources of support or clinical care. In addition, unemployment, poverty, demoralisation and opioid abuse have been identified as important risk factors. Notably, overall longevity rates in the US, though rising for many decades, have recently been declining, in part owing to suicide and substance overdoses. A particular circumstance associated with strikingly high rates of suicides and attempts is the days and weeks following discharge from psychiatric hospitalisation. Although the incidence of such events is low, there is a need for more secure aftercare planning and implementation. Research on therapeutics aimed at reducing suicidal risk and all-cause mortality among psychiatric patients remains severely under-developed.

Disparities in Access to Mental Health Services Among Patients Hospitalized for Deliberate Drug Overdose

OBJECTIVE

The authors examined patient and hospitalization characteristics associated with receiving a mental health assessment and disposition to an inpatient psychiatric facility among patients hospitalized for deliberate drug overdose.

METHODS

This retrospective analysis of 2012-2013 South Carolina all-payer data included adults ages 18-64 with at least one inpatient admission for a primary diagnosis of deliberate illicit or pharmaceutical drug overdose (N=2,686). Outcomes were receipt of a mental health assessment and disposition to an inpatient psychiatric facility. Multivariable logistic regression models were used to estimate the effects of patient and hospitalization characteristics on study outcomes.

RESULTS

Non-Hispanic blacks and people of other races-ethnicities were less likely than non-Hispanic whites to receive a mental health assessment (non-Hispanic blacks, adjusted odds ratio [AOR]=0.52, 95% CI=0.34-0.81; other races-ethnicities, AOR=0.24, 95% CI=0.12-0.49). Non-Hispanic blacks were also less likely than non-Hispanic whites to be discharged to an inpatient psychiatric facility than to home (AOR=0.60, 95% CI=0.47-0.77). Compared with persons without insurance, those with insurance, except those with Medicaid, were more likely to be discharged to an inpatient psychiatric facility than to home (Medicare, AOR=3.06, 95% CI=2.36-3.96; private, AOR=2.78, 95% CI=2.23-3.47; other, AOR=7.58, 95% CI=4.21-13.6).

CONCLUSIONS

Non-Hispanic white race-ethnicity and having insurance were predictive of receipt of a mental health assessment and disposition to an inpatient psychiatric facility among patients hospitalized for deliberate drug overdose. Study findings can inform clinical strategies and interventions aimed at reducing mental health care disparities among populations who are vulnerable to overdose or suicide.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Widespread emergency department access block: a human rights issue in Australia?

OBJECTIVE:

There are increasing demands on emergency psychiatrists with higher numbers of mental health presentations, and longer stays in emergency departments (EDs). Australia, like other English speaking countries, funds considerably lower numbers of psychiatric beds than average for Organisation for Economic Co-operation and Development (OECD) countries. Consequently, acute bed occupancy is high, and a bed is frequently unavailable when a person needs admission. Patients with serious mental illness can wait days in busy and overstimulating EDs, become agitated and assaultive, and then require chemical and physical restraint. All patients have a right to safe high quality care, but the paucity of beds deprives patients of this right. The Australasian College of Emergency Medicine recommends reporting ED access block to health ministers, and human rights and/or health rights commissioners, and recommends increased funding for inpatient psychiatric care, emergency mental health and after-hours community services, together with more alcohol and other drug programs.

CONCLUSIONS:

It is challenging for emergency physicians and psychiatrists to provide optimal care for acutely unwell patients who stay extended periods in the ED. Increasing the availability of inpatient care must be considered as part of a comprehensive solution for minimising ED lengths of stay in Australia.

Trends in Pediatric Emergency Department Visits for Mental Health Conditions and Disposition by Presence of a Psychiatric Unit

OBJECTIVE

To examine trends in mental health (MH) visits to pediatric emergency departments (EDs) and identify whether ED disposition varies by presence of a hospital inpatient psychiatric unit (IPU).

STUDY DESIGN

Cross-sectional study of 8,479,311 ED visits to 35 children's hospitals from 2012 to 2016 for patients aged 3 to 21 years with a primary MH or non-MH diagnosis. Multivariable generalized estimating equations and bivariate Rao-Scott chi-square tests were used to examine trends in ED visits and ED disposition by IPU status, adjusted for clustering by hospital.

RESULTS

From 2012 to 2016, hospitals experienced a greater increase in ED visits with a primary MH versus non-MH diagnosis (50.7% vs 12.7% cumulative increase, P < .001). MH visits were associated with patients who were older, female, white non-Hispanic, and privately insured compared with patients of non-MH visits (all P < .001). Forty-four percent of MH visits in 2016 had a primary diagnosis of depressive disorders or suicide or self-injury, and the increase in visits was highest for these diagnosis groups (depression: 109.8%; suicide or self-injury: 110.2%). Among MH visits, presence of a hospital IPU was associated with increased hospitalizations (34.6% vs 22.5%, P < .001) and less transfers (9.2% vs 16.2%, P < .001).

CONCLUSION

The increase in ED MH visits from 2012 to 2016 was 4 times greater than non-MH visits at US children's hospitals and was primarily driven by patients diagnosed with depressive disorders and suicide or self-injury. Our findings have implications for strategic planning in tertiary children's hospitals dealing with a rising demand for acute MH care.

A qualitative analysis of suicidal psychiatric inpatients views and expectations of psychological therapy to counter suicidal thoughts, acts and deaths

BACKGROUND

Suicide is a global problem and suicidal behavior is common in acute psychiatric wards. Inpatient suicides regularly occur with 10.4/100,000 such deaths recorded in the UK in 2016. Inpatient suicides are potentially the most avoidable of all suicides as inpatients have 24-h staff contact. Current inpatient treatment prioritizes maintenance of physical safety by observation, medication and general supportive measures, however efficacious and effective specific treatments are lacking. Psychological treatments have a growing evidence base for suicide prevention yet provision of inpatient therapy is uncommon. The present qualitative study aimed to understand the patient acceptability issues by investigating suicidal inpatients views and expectations of a novel suicide-focussed cognitive behavioural psychological therapy which was nested alongside a pilot clinical trial of the intervention.

METHODS

Thematic analysis of semi-structured individual qualitative interviews with twenty suicidal psychiatric inpatients to investigate their views and expectations about ward-based suicide-focused psychological treatment.

RESULTS

Two main themes were identified. The first, 'A therapy that works', revealed inpatients' views of the necessary components for effective ward-based suicide-focused psychological therapy. The second, 'Concerns about in-patient suicide-focused therapy', depicted their fears about engaging in this treatment. Results suggested that suicide-focused psychological therapy was cautiously welcomed by inpatients' whose narratives expressed their needs, priorities and concerns. Further data analysis enabled formation of a user-informed model of suicide-focussed psychological therapy which offers guidance for researchers and clinicians.

CONCLUSIONS

We conclude that hospitalization of suicidal individuals offers a critical opportunity to intervene with effective treatment to preserve life and that suicide-focussed psychological therapy is likely to be well received by suicidal inpatients warranting further testing with a sufficiently powered definitive trial. It is important that provision of ward-based psychological therapy for suicidal inpatients addresses the considerable context-specific challenges inherent in this setting.

TRIAL REGISTRATION NUMBER

ISRCTN 17890126 , Registry: UK Clinical Trials Gateway, Date of registration: 22/04/15, Date of enrolment of first participant to the trial: 20/05/14 (retrospectively registered).

Forty years without mental hospitals in Italy

In 1978 Italy implemented Law Number 180, the reform law that blocked all new admissions to public mental hospitals. After 40 years without mental hospitals, we aim at understanding the consequences of the Italian reform in terms of mental health care facility and staff availability. We compared the organization of the Italian mental health system with that of countries belonging to the Group of 7 (G7) major advanced economies. Italy has nearly 8 psychiatrists, 20 nurses, 2 social workers and less than 3 psychologists per 100,000 population, while for example in France there were 22 psychiatrists, in Japan 102 nurses, in the United States 18 social workers, and in Canada and France more than 45 psychologists per 100,000 population. In terms of inpatient facilities, no beds in mental hospitals were available in Italy, while in the other G7 countries mental hospital beds ranged from 8 in the United Kingdom to 204 in Japan per 100 000 population. In Italy there were fewer beds for acute care in general hospitals but more beds in community residential facilities than in the other G7 countries. Service use data showed variability in the provision of mental health care throughout the country. Soon after the implementation of the Italian reform the absolute number of compulsory admissions progressively declined, from more than 20,000 in 1978 to less than 9000 in 2015. Alongside the progressive decline of psychiatric beds imposed by Law 180, the age-adjusted suicide rate remained stable, ranging from 7·1/100,000 population in 1978 to 6·3/100,000 population in 2012. The population of psychiatric patients placed in Italian forensic psychiatric hospitals progressively declined. During the last 40 years without mental hospitals, Italy has seen a progressive consolidation of a community-based system of mental health care. We highlighted, however, reasons for concern, including a decreasing staffing level, a potential use of community residential facilities as long-stay residential services, a still too high variability in service provision across the country, and lack of national data on physical restraints. At a national level, the resources allocated to mental health care are lower in Italy than in other high-income countries.

County Jail or Psychiatric Hospital? Ethical Challenges in Correctional Mental Health Care

Approximately 20% of the roughly 2.5 million individuals incarcerated in the United States have a serious mental illness (SMI). As a result of their illnesses, these individuals are often more likely to commit a crime, end up incarcerated, and languish in correctional settings without appropriate treatment. The objective of the present study was to investigate how correctional facility personnel reconcile the ethical challenges that arise when housing and treating individuals with SMI. Four focus groups and one group interview were conducted with employees ( n = 24) including nurses, clinicians, correctional officers, administrators, and sergeants at a county jail in Pennsylvania. Results show that jail employees felt there are too many inmates with SMI in jail who would benefit from more comprehensive treatment elsewhere; however, given limited resources, employees felt they were doing the best they can. These findings can inform mental health management and policy in a correctional setting.

When should governments increase the supply of psychiatric beds?

Low numbers of hospital-based psychiatric beds create problems for people with severe mental illness (SMI), when they face extended emergency department (ED) waits, higher thresholds for admission to an acute bed, and short revolving-door stays with high rates of rehospitalisation. Limited access to inpatient treatment has been associated with higher suicide risk, premature mortality, homelessness, violent crime and incarceration. Ultimately, people with SMI can be transinstitutionalised to the criminal justice system. In the USA, for example, prisons have replaced mental hospitals as the largest institutions housing people with SMI. There is no international consensus on the safe minimum numbers of acute, forensic and rehabilitation beds needed to reduce these risks. As a consequence, Organisation for Economic Cooperation and Development (OECD) countries have wide variations in the mix of hospital beds with an average of 71 beds per 100 000 population. Policymakers face difficult choices with few studies to guide decisions on supplying beds. The UK Royal College of Psychiatrists offered a policy framework, which was adapted for Australia. The government of the State of South Australia increased the supplies of crisis, acute and forensic beds to meet a mandatory target to safely reduce mental health boarding in the EDs.

Social inequality, scientific inequality, and the future of mental illness

BACKGROUND

Despite five decades of increasingly elegant studies aimed at advancing the pathophysiology and treatment of mental illness, the results have not met expectations. Diagnoses are still based on observation, the clinical history, and an outmoded diagnostic system that stresses the historic goal of disease specificity. Psychotropic drugs are still based on molecular targets developed decades ago, with no increase in efficacy. Numerous biomarkers have been proposed, but none have the requisite degree of sensitivity and specificity, and therefore have no usefulness in the clinic. The obvious lack of progress in psychiatry needs exploration.

METHODS

The historical goals of psychiatry are reviewed, including parity with medicine, a focus on diagnostic reliability rather than validity, and an emphasis on reductionism at the expense of socioeconomic issues. Data are used from Thomas Picketty and others to argue that our failure to advance clinical care may rest in part on the rise in social and economic inequality that began in the 1970s, and in part on our inability to move beyond the medical model of specificity of disease and treatment.

RESULTS

It is demonstrated herein that the historical goal of specificity of disease and treatment has not only impeded the advance of diagnosis and treatment of mental illness, but, in combination with a rapid increase in socioeconomic inequality, has led to poorer outcomes and rising mortality rates in a number of disorders, including schizophrenia, anxiety, and depression.

CONCLUSIONS

It is proposed that Psychiatry should recognize the fact of socioeconomic inequality and its effects on mental disorders. The medical model, with its emphasis on diagnostic and treatment specificity, may not be appropriate for investigation of the brain, given its complexity. The rise of scientific inequality, with billions allocated to connectomics and genetics, may shift attention away from the need for improvements in clinical care. Unfortunately, the future prospects of those suffering from mental illness appear dim.

Suicide Rates and the Declining Psychiatric Hospital Bed Capacity in the United States

This analysis discusses the association between the availability of psychiatric hospital beds and suicide rates in the United States.

Sex Differences in the Peripheral Immune System in Patients with Depression

BACKGROUND

Females are twice as likely as males to experience depression. Recent findings indicate a relationship linking inflammation with depression. Whether the higher prevalence of depression in women is sex-specific or if inflammation contributes to a higher prevalence of depression in females is unclear. Thus, the objective was to determine whether depressed females show higher inflammation compared to males in a cross-sectional study.

MATERIALS AND METHODS

Two hundred participants were enrolled. Depressive symptoms were assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS), and blood samples were collected from all participants to measure inflammatory blood markers.

RESULTS

Higher rates of suicidal thoughts, pessimism, and lassitude measured by the MADRS were seen in depressed females compared with depressed males. Among all inflammatory markers measured, there were no significant differences in depressed males vs. male controls. Increased levels of interleukin (IL)-8, interferon-γ, and leptin, and decreased levels of IL-5 and adiponectin were observed in depressed females compared to female controls. Compared with depressed males, IL-6 and leptin levels were significantly elevated in depressed females after controlling for body mass index. Correlation analysis revealed that depression severity negatively correlated with IL-12 in males, and positively correlated with IL-1β and tumor necrosis factor (TNF)-α in females. IL-1β and TNF-α correlated with suicidal thoughts, lassitude, and pessimism in depressed females.

CONCLUSION

Our findings indicate a sex-specific relationship between inflammation and depression, which may be important in identifying potential psychopathology and suggesting novel immunomodulatory treatments for depressed females.