[Increasing suicides of psychiatric inpatients: reality or artefact? (author's transl)]

[Suicide in psychiatric hospitals : Results, risk factors and therapeutic measures]

Suicide prevention is a core responsibility of psychiatry and psychotherapy. Periods of change in psychiatric inpatient treatment concepts are usually also accompanied by an increase in psychopathological behavior and with increased suicide rates in psychiatric hospitals, as seen in the 1970s and 1980s in Germany. That this represented a real increase of inpatient suicides during those years was confirmed and subsequently the number and rate of inpatient suicides has decreased from approximately 280 out of 100,000 admissions of patients in 1980 to approximately 50 in 2014. Death can also occur in psychiatric hospitals and an absolute prevention is not possible even under optimal conditions of therapy and nursing, communication and security. The suicide rate has clearly decreased over the last two decades in relation to admissions. The group of young male schizophrenic patients newly identified as having a high clinical suicide risk has decreased among the suicide victims whereas the percentage of severely depressed patients with delusions has increased. This reduction could be associated with the comprehensive improvements in educational and training programs in the field of suicide and suicide prevention, objectification of coping methods, development of diagnostic and therapeutic strategies, improvements in therapy and relationship possibilities and a general reduction in the number of suicides in Germany.

Suicide inside: a systematic review of inpatient suicides

The literature on inpatient suicides was systematically reviewed. English, German, and Dutch articles were identified by means of the electronic databases PsycInfo, Cochrane, Medline, EMBASE psychiatry, CINAHL, and British Nursing Index. In total, 98 articles covering almost 15,000 suicides were reviewed and analyzed. Rates and demographic features connected to suicides varied substantially between articles, suggesting distinct subgroups of patients committing suicide (e.g., depressed vs. schizophrenic patients) with their own suicide determinants and patterns. Early in the admission is clearly a high-risk period for suicide, but risk declines more slowly for patients with schizophrenia. Suicide rates were found to be associated with admission numbers, and as expected, previous suicidal behavior was found to be a robust predictor of future suicide. The methods used for suicide are linked to availability of means. Timing and location of suicides seem to be associated with absence of support, supervision, and the presence of family conflict. Although there is a strong notion that suicides cluster in time, clear statistical evidence for this is lacking. For prevention of suicides, staff need to engage with patients' family problems, and reduce absconding without locking the door. Future research should take into account the heterogeneous subgroups of patients who commit suicide, with case-control studies addressing these separately.

Changes in suicide numbers in psychiatric hospitals: an analysis using log-linear time-trend models

We examined the hypothesis that there is an increase in the number of suicides committed by psychiatric inpatients. Data were recorded in five psychiatric hospitals/departments in Baden-Württemberg (Germany) for the period between 1970 and 1992. Statistical analysis was performed by means of log-linear time-trend models that allowed us to test several hypothesis, to compare their goodness of fit, and to correct for related factors (number of admissions, number of suicides in the general population). Results showed that the model of a general increase could be rejected. The separation of the yearly frequencies into two parts (1970-1979 and 1980-1992) revealed an increase in the inpatient suicide rate during the years 1970-1979 and a slowly decreasing inpatient suicide rate during the years 1980-1992, especially when taking admission numbers into account. Diagnostic subgroups (schizophrenia and depression) did not seem to deviate from these trends. The correction for the suicide numbers in the general population of Baden-Württemberg, which exhibited a remarkable decrease in the 1980s, did not influence these results. We speculate that, after some starting difficulties, the effects of the more humane treatment procedures introduces in the 1970s are beginning to be felt.

Three different types of clinical suicide

A total of 149 inpatients were identified who had committed suicide in two Swiss psychiatric institutions in the years 1960-1981. Using Research Diagnostic Criteria, 49 were diagnosed as schizophrenics, 75 as depressives, and 9 as alcoholics. The first two groups were significantly overrepresented and the third one underrepresented when compared with a control sample. There were considerable differences between the individual diagnostic groups of clinical suicides: schizophrenic suicides were characterized by a disturbed early social adjustment, a high degree of later disability and an unfavorable course of their illness, depressive suicides were much less handicapped, although they presented a much higher long-term suicidal potential, and alcoholic suicides demonstrated no signs of suicidal behavior in the clinic and committed suicide unexpectedly after experiencing negative life events. These findings have therapeutic implications.

[Mortality of schizophrenic patients--a study of 170 cases]

170 schizophrenic patients, who were treated, between 1971 and 1973, in a mental hospital, in 2 night clinics and a social psychiatric outpatient clinic, were examined, 12 to 13 years later, with regard to rate of death. 7 of the 46 night clinic patients, 1.4% per year, and 2 of the 46 hospital patients, 0.4% per year, had died, all of them by suicide or a psychotic motivated self-destructive act. 16 of the 78 outpatients had died, 1.5% per year, whereby 10 committed suicide (0.99% per year). In comparison with the Swiss mortality tables and accounting for sex and age factors, the death rate by the examined schizophrenics is significantly higher.

Suicide in psychiatric patients in Denmark, 1971-81. I. Demographic and diagnostic description

Data concerning all suicide cases in Denmark with a psychiatric history (1971-81) were compiled through computer record linkage between central registers. Cases of suicide during and up to 1 year after inpatient hospitalization were investigated. 21% of the suicides took place while the patient was still hospitalized. The overall suicide rates increased slightly faster than in the population without recent psychiatric hospitalization. There were few suicides in the groups over 65 and under 25 years of age. A sharp relative increase in suicide mortality in the provincial and particularly rural populations was noted. Approximately half of the patients were psychotic, mainly with major affective disorder. The percentage of patients with neurosis or personality disorder decreased. 37% of the men and 18% of the women were diagnosed as substance abusers. Fairly consistently, approximately 10% of the suicide victims were characterized by affective reactions or no psychiatric illness.

Antidepressive therapy in depressed clinical suicides

A total of 61 clinical suicides, all of them fulfilling the Research Diagnostic Criteria for a depressive disorder, were examined with regard to the psychopharmacological treatment they received at the time of their suicide. Scarcely half were treated with antidepressants, and only a small minority were optimally treated. One of the reasons for this therapeutic inadequacy lies in a discrepancy between the clinical and RDC diagnoses. An improvement in diagnostic practice, in the sense of paying more attention to the presence of a depressive syndrome, along with an improvement in psychopharmacological treatment, could contribute to a reduction in the clinical suicide rate, which has recently been observed to be increasing.

Suicide among psychiatric patients of a district general hospital

Twenty-two psychiatric patients who committed suicide while receiving hospital treatment or within 3 months of discharge from psychiatric care were studied using general population statistics, a random sample of 100 psychiatric patients and a control group matched individually with the hospital suicides. The rate of suicide among psychiatric in-patients was over 50 times that in the general population. A higher vulnerability to suicide was detected among in-patients (v. other patient groups), men (v. women) and middle-aged patients (v. older and younger patients). Suicides were differentiated from controls in having suffered more losses (P less than 0.05), being psychiatrically ill for the first time (P less than 0.05), having a past history of deliberate self-harm (P less than 0.05), and not receiving a schizophrenic diagnosis (P less than 0.02). People with mid-life crises, patients who swing rapidly into depression while receiving treatment, and individuals who are judged to be depressed because of personal problems may carry a particularly high suicide risk during psychiatric treatment.

Association between changes in psychiatric services and increases in suicide rates

The purpose of the study is to discover whether there is an association between changes in the psychiatric services offered by the largest psychiatric hospital in Iceland during the period 1955-1978 and changes in the rate of suicide. Marked changes occurred in the services after 1965. The rate of suicide in the patient population was significantly higher during 1965-1978 than during 1955-1964. It is concluded that the changes in the psychiatric services are associated with an increase in the rate of suicide and that this increase may to some extent be a side effect of therapeutic methods introduced after 1965. The conclusion is thought to imply the necessity for further evaluation of those therapeutic methods as applied in the hospital and increasing the application of measures for the prevention of suicide.