In-patient suicide--a 13-year assessment

Inpatient suicide in psychiatric settings: Evaluation of current prevention measures

The risk of suicide in psychiatric hospitals is 50 times higher than in the general population, despite patient safety being a priority for any hospital. However, to date, due to the complexity of assessing suicide risk, there has been no consensus on the suicide prevention measures that should be in place in hospitals. The aim of this work is: To provide an overview of the progress that has been made in the field of inpatient suicide prevention in recent years; discuss the problems that remain; and suggest potential future developments. As new clinical dimensions (notably anhedonia, psychological pain and hopelessness) develop, they should become new therapeutic targets. Team training (like the Gatekeeper Training Program) and the latest advances in suicide risk assessment (such as the Collaborative Assessment and Management of Suicidality) should be implemented in psychiatric wards. Suicide prevention plans (e.g., ASSIP, SAFE-T, etc.) represent easy-to-administer, low-cost interventions. The Mental Health Environment of Care Checklist has been proven effective to reduce suicide risk at hospitals. Furthermore, the types of psychotherapy recommended to reduce suicide risk are cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT). There are several pharmacological treatments for suicide risk, such as lithium and clozapine, which have been shown to be effective in the long term, as well as ketamine and esketamine, which are more effective in the short term. Following some encouraging recent results, buprenorphine may also be proposed to patients with a suicide risk. Triple chronotherapy rapidly improves depressive symptoms over 9 weeks. Regarding brain stimulation techniques, rTMS has proven to be effective in alleviating multiple dimensions of suicidality.

Suicide in Psychiatric Inpatients- A Case-Control Study

Objective: Psychiatric inpatients constitute a population at considerably increased risk for suicide. Identifying those at imminent risk is still a challenging task for hospital staff. This retrospective case-control study focused on clinical risk factors related to the course of the hospital stay. Method: Inpatient suicide cases were identified by linking the Tyrol Suicide Register with the registers of three psychiatric hospitals in the state. Control subjects were patients who had also been hospitalized in the respective psychiatric unit but had not died by suicide. Matching variables included sex, age, hospital, diagnosis, and admission date. The study period comprised 7 years. Data were analyzed by the appropriate two-sample tests and by logistic regression. Results: A total of 30 inpatient suicide cases and 54 control patients were included. A number of factors differentiated cases from controls; after correction for multiple testing, the following retained significance: history of aborted suicide, history of attempted suicide, history of any suicidal behavior/threats, suicidal ideation continuing during hospitalization, no development of prospective plans, no improvement of mood during the hospital stay, and leaving ward without giving notice. Logistic regression identified the latter three variables and history of attempted suicide as highly significant predictors of inpatient suicide. Conclusions: Preventive measures during hospitalization include thorough assessment of suicidal features, an emphasis on the development of future perspectives, and a review of hospital regulations for patients who want to leave the ward.

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.

Rethinking suicides as mental accidents: Towards a new paradigm

BACKGROUND

Since its beginnings, suicide research has made great progress in terms of empirical findings. However, in contrast to empirical knowledge, the theoretical understanding of suicides has shown only minimal progress. Missing interdisciplinary bridges and the lack of a unifying paradigm have been major obstacles. This paper examines the starting points for a rethink.

METHODS

In the first step, we identified major challenges in suicide research, which have been obstructing a better understanding. In the second step, we determined a new concept of suicide that is highly compatible with epidemiological results and meets the requirements of interdisciplinary usability. In the third step, the implications of this paradigm were explored by relating it to two process typologies, the one characterizing the temporal dynamics of suicide processes, and the other representing risk mechanisms / factors occurring at different stages of suicide processes.

RESULTS

Since suicides are rare events and often appear to be "rash acts", they can be conceived of as mental accidents or, more precisely, as failures to withstand temporary suicide impulses. This paradigm is suitable for synchronously implementing different personal, psychopathological, societal and situational perspectives. It applies to a high proportion of suicides and works well when being exposed to different typologies of suicide processes.

CONCLUSIONS

The mental accident paradigm provides an interdisciplinary starting point in suicidology that offers new perspectives in research, prediction and prevention.

Positive mental health as a moderator of the association between risk factors and suicide ideation/behavior in psychiatric inpatients

In recent studies positive mental health has been shown as a resilience factor related to suicide ideation/behavior. It is not known if positive mental health buffers the effect of various risk factors (depression, perceived burdensomeness, hopelessness, childhood maltreatment) on suicide ideation/behavior in psychiatric inpatients-a high risk population. A total of 100 psychiatric inpatients were included in the survey. Four hierarchical regression analyses were conducted to examine, whether positive mental health moderates the association between the four risks factors and suicide ideation/behavior. Positive mental health was shown to moderate the association between perceived burdensomeness and suicide ideation/behavior. The association between the other three risk factors and suicide ideation/behavior was not moderated by positive mental health. Given the cross-sectional nature of the data, conclusions on causality cannot be drawn. The buffering effect of positive mental health suggests that positive mental health may improve the identification of individuals at risk of suicide ideation/behavior and may be an important area to target in the prevention and treatment of individuals at risk of suicide. Further research is needed.

Springtime Peaks and Christmas Troughs: A National Longitudinal Population-Based Study into Suicide Incidence Time Trends in the Netherlands

BACKGROUND

Time trends are one of the most studied phenomena in suicide research; however, evidence for time trends in the Dutch population remains understudied. Insight into time trends can contribute to the development of effective suicide prevention strategies.

METHODS

Time trends in national daily and monthly data of 33,224 suicide events that occurred in the Netherlands from 1995 to 2015 were examined, as well as the influence of age, gender, and province, in a longitudinal population-based design with Poisson regression analyses and Bayesian change point analyses.

RESULTS

Suicide incidence among Dutch residents increased from 2007 until 2015 by 38%. Suicide rates peak in spring, up to 8% higher than in summer (p < 0.001). Suicide incidence was 42% lower at Christmas, compared to the December-average (IRR = 0.580, p < 0.001). After Christmas, a substantial increase occurred on January 1, which remained high during the first weeks of the new year. Suicide occurred more than twice as often in men than in women. For both genders, the results indicated a spring time peak in suicide incidence and a trough at Christmas. Suicide rates were highest in the elderly (age group, 80+), and no evidence was found of a differential effect by season in the age groups with regard to suicide incidence. No interaction effect was found with regard to province of residence for both season and Christmas, indicating that no evidence was found that these time trends had differential effects in the Dutch provinces in terms of suicide incidence.

CONCLUSION

Evidence was found for time trends in suicide incidence in the Netherlands. It is recommended to plan (mental) health care services to be available especially at high-risk moments, at spring time, and in the beginning of January. Further research is needed to explore the protective effect of Christmas in suicide incidence.

The investigation of the relationship between probability of suicide and reasons for living in psychiatric inpatients

AIM

This study was carried out to determine the reasons of the suicide probability and reasons for living of the inpatients hospitalized at the psychiatry clinic and to analyze the relationship between them.

MATERIALS AND METHODS

The sample of the study consisted of 192 patients who were hospitalized in psychiatric clinics between February and May 2016 and who agreed to participate in the study. In collecting data, personal information form, suicide probability scale (SPS), reasons for living inventory (RFL), and Beck's depression inventory (BDI) were used. Stepwise regression method was used to determine the factors that predict suicide probability.

RESULTS

In the study, as a result of analyses made, the median score on the SPS was found 76.0, the median score on the RFL was found 137.0, the median score on the BDI of the patients was found 13.5, and it was found that patients with a high probability of suicide had less reasons for living and that their depression levels were very high. As a result of stepwise regression analysis, it was determined that suicidal ideation, reasons for living, maltreatment, education level, age, and income status were the predictors of suicide probability (F = 61.125; P < 0.001).

DISCUSSION

It was found that the patients who hospitalized in the psychiatric clinic have high suicide probability and the reasons of living are strong predictors of suicide probability in accordance with the literature.

Risk Estimates and Risk Factors Related to Psychiatric Inpatient Suicide-An Overview

People with mental illness have an increased risk of suicide. The aim of this paper is to provide an overview of suicide risk estimates among psychiatric inpatients based on the body of evidence found in scientific peer-reviewed literature; primarily focusing on the relative risks, rates, time trends, and socio-demographic and clinical risk factors of suicide in psychiatric inpatients. Psychiatric inpatients have a very high risk of suicide relative to the background population, but it remains challenging for clinicians to identify those patients that are most likely to die from suicide during admission. Most studies are based on low power, thus compromising quality and generalisability. The few studies with sufficient statistical power mainly identified non-modifiable risk predictors such as male gender, diagnosis, or recent deliberate self-harm. Also, the predictive value of these predictors is low. It would be of great benefit if future studies would be based on large samples while focusing on modifiable predictors over the course of an admission, such as hopelessness, depressive symptoms, and family/social situations. This would improve our chances of developing better risk assessment tools.

Inter-rater reliability of the German version of the Nurses' Global Assessment of Suicide Risk scale

In comparison to the general population, the suicide rates of psychiatric inpatient populations in Germany and Switzerland are very high. An important preventive contribution to the lowering of the suicide rates in mental health care is to ensure that the risk of suicide of psychiatric inpatients is assessed as accurately as possible. While risk-assessment instruments can serve an important function in determining such risk, very few have been translated to German. Therefore, in the present study, we reported on the German version of Nurses' Global Assessment of Suicide Risk (NGASR) scale. After translating the original instrument into German and pretesting the German version, we tested the inter-rater reliability of the instrument. Twelve video case studies were evaluated by 13 raters with the NGASR scale in a 'laboratory' trial. In each case, the observer's agreement was calculated for the single items, the overall scale, the risk levels, and the sum scores. The statistical data analysis was conducted with kappa and AC1 statistics for dichotomous (items, scale) scales. A high-to-very high observers' agreement (AC1: 0.62-1.00, kappa: 0.00-1.00) was determined for 16 items of the German version of the NGASR scale. We conclude that the German version of the NGASR scale is a reliable instrument for evaluating risk factors for suicide. A reliable application in the clinical practise appears to be enhanced by training in the use of the instrument and the right implementation instructions.

A comparison of suicides in psychiatric in-patients, after discharge and in not recently hospitalized individuals

OBJECTIVE

Time of in-patient treatment and the first weeks after hospital discharge have repeatedly been described as periods of increased suicide risk. This study compared demographic, clinical and suicide related factors between in-patient, post-discharge and not recently hospitalized suicides.

METHODS

Suicide data from the Tyrol Suicide Register were linked with registers of three psychiatric hospitals in the state of Tyrol, Austria. Suicide cases then were categorized as in-patient suicides, post-discharge suicides (suicide within 12weeks after discharge) or never/not within 12weeks before death hospitalized suicides. Data were collected between 2004 and 2011.

RESULTS

Of the total of 711 cases, 30 were in-patient, 89 post-discharge and 592 not recently hospitalized suicides. The three groups differed with regard to male-to-female ratio (lower in both hospitalized groups), marital status, suicide method used (jumping in in-patients, hanging in not recently hospitalized suicides), history of attempted suicide and suicide threats (highest in in-patients) and whether suicides had been in psychiatric or general practitioner treatment shortly before death. In most variables with significant differences there was a gradual increase/decrease with post-discharge suicides taking the middle place between the two other groups.

CONCLUSIONS

The three suicide populations differed in a number of variables. Varying factors appear to influence suicide risk and choice of method differently in in-patient, post-discharge and not hospitalized suicides.

Suicide in hospitalized early psychosis patients at the time of discharge from hospital: An exploratory study of attempters and nonattempters

BACKGROUND

Early intervention programs for psychosis are gateways for suicide prevention. These programs offer an excellent opportunity for prevention due to easy access, early identification, and provisions for continuity of care. These programs have been found effective in reducing rates of suicide after discharge to communities. The objective of this study was to examine suicide risk level among early psychosis patients admitted with and without previous suicide attempts. We hypothesized that all patients admitted with early psychosis would be at high risk of suicide, regardless of a previous suicide attempt.

METHODOLOGY

Suicide risk was compared between patients admitted with a suicide attempt (n = 30) and patients admitted without a suicide attempt (n = 30). The primary outcome measure of interest was suicide risk which was measured with the Scale for Impact of Suicidality-Management, Assessment and Planning of Care clinical interview. All patients met DSM-IV TR criteria for schizophrenia. Psychopathology was assessed using the Brief Psychiatric Rating Scale and level of depression was assessed using the Hamilton Depression Rating Scale. The data were statistically analyzed.

RESULTS

Patients admitted with a previous attempt (mean = 29.5, standard deviation [SD] =12.0) did not differ significantly in suicide risk from those admitted without a previous attempt (mean = 27.5, SD = 12.5), (t[58] =0.63, P = 0.53). Patients admitted without a suicide attempt scored higher in depressive symptoms (t[58] =10.62, P < 0.001) than that of admitted with a suicide attempt. There were no significant differences between patients admitted with and without suicide attempts on any comorbidity, other than a trend toward a higher prevalence of personality disorder in patients with no suicide attempt. Attempters and nonattempters did not differ on any demographic variables either.

CONCLUSIONS

Of those admitted without a previous suicide attempt, our findings suggest that it is critical that all patients discharged from an acute psychiatric unit must receive comprehensive community care. The identification of risk, and subsequent intervention for suicidal and self-harm behaviors, should be a central part of treatment for all mental disorders.

Depression and the Suicidal Patient

Depression is the most common psychiatric illness in the general community, with 3% to 4% of depressives dying by suicide today. Studies have shown that depression has considerable morbidity and mortality. This article focuses on depressed patients and their management within the emergency department. Understanding the intricacies of the interview process and identifying which patients need immediate attention are important skills for the emergency physician.

Meta-analysis of suicide rates among psychiatric in-patients

OBJECTIVE

To examine factors associated with the number of psychiatric admissions per in-patient suicide and the suicide rate per 100,000 in-patient years in psychiatric hospitals.

METHOD

Random-effects meta-analysis was used to calculate pooled estimates, and meta-regression was used to examine between-sample heterogeneity.

RESULTS

Forty-four studies published between 1945 and 2013 reported a total of 7552 in-patient suicides. The pooled estimate of the number of admissions per suicide calculated using 39 studies reporting 150 independent samples was 676 (95% CI: 604-755). Recent studies tended to report higher numbers of admissions per suicide than earlier studies. The pooled estimate of suicide rates per 100,000 in-patient years calculated using 27 studies reporting 95 independent samples was 147 (95% CI: 138-156). Rates of suicide per 100,000 in-patient years tended to be higher in more recent samples, in samples from regions with a higher whole of population suicide rate, in samples from settings with a shorter average length of hospital stay and in studies using coronial records to define suicide.

CONCLUSION

Rates of in-patient suicide in psychiatric hospitals vary remarkably and are disturbingly high. Further research might clarify the extent to which patient factors and the characteristics of in-patient facilities contribute to the unacceptable mortality in psychiatric hospitals.

[Psychiatry with open doors. Part 2: Therapeutic challenges]

In the previous part of the issue we argued that opening the doors of acute psychiatric inpatient wards is actually one of the anchor points on the way to an innovative psychiatry. It focuses on the patient's personality in a sense that this is taken as seriously as the psychiatric disorder itself. Patients and relatives should be enabled to participate in treatment decisions as they should experience that treatment teams are concerned about reliance, liability and security in therapeutic relationships in an empathetic way. The second part of the issue contributes to the therapeutic measures, the different skills and modifications of treatment frameworks in acute psychiatry (e.g. prevention of crowding in acute psychiatric inpatient units, education of staff, assessment of the risks of violence, de-escalation strategies and coping with suicidality). They might be helpful in implementing the outlined confidence about the essence of therapeutic relationships, autonomy and codetermination of patients in treatment. These suggestions might enhance a professional approach particularly with respect to prevention and also concerning acute interventions in situations of endangerment to self and others and of aggression and violence in the units. In this way they help to achieve the goal of open doors in psychiatry.

Inpatient suicide prevention: promoting a culture and system of safety over 30 years of practice

In April 2012, the Joint Commission (JC) report noted that psychiatric hospitals were the most frequent setting for a sentinel event. In 2010-12, suicide was among the top 5 causes of a sentinel event and was a more frequent cause of sentinel events than medication errors. Suicide was ranked as the 10th leading cause of death among persons 10 years of age and older, accounting for 36,891 deaths in 2009. Previous research on suicide has focused on patient evaluation, disease management, symptom assessment, and the use of risk prevention tools, but few publications have reported on system-wide integrated approaches to successful suicide prevention. In this article on inpatient suicide prevention, I present the successful strategies based on epidemiological findings that have been used in one institution to reduce inpatient suicide risk. This report covers strategies that have been used for over 32 years in the treatment of more than 60,000 patients. The successful prevention efforts described in this article involved staff training and deployment, thorough patient assessment, environmental protections, complete handouts, and patient care protocols.

Protective and risk factors for inpatient suicides: a nested case-control study

This study aimed at estimating the protective effect of suicide precautions and clinical risk factors for inpatient suicides. A standardized precaution system was implemented in a large psychiatric center on January 1, 1996. A consecutive series of 33,121 admissions from 1998 to 2008 constituted the post-implementation cohort and 13,515 admissions from 1985 to 1995 constituted the pre-implementation cohort as comparison group. Inpatient suicides were identified via record linkage with national mortality database. For each of 41 inpatient suicides, four controls were randomly selected based on a nested case-control study. A standardized chart review process was employed to collate clinical information for each study subject. Risk and protective factors for inpatient suicides was estimated by conditional logistic regression. The findings showed that, among subjects with shorter lengths of stay, those admitted in post-implementation era had a significantly lower adjusted risk ratio (0.157, p=0.048) for inpatient suicides. Three depression-related symptoms elevated the risk for inpatient suicides: depressed mood (adjusted risk ratio=2.11, P=0.002), loss of energy (adjusted risk ratio=1.99, P=0.018), and psychomotor retardation (adjusted risk ratio=1.67, P=0.066; with marginal statistical significance). Suicide precautions have protective effect against inpatient suicides. A better assessment and prevention efforts is needed, particularly for those with depression-related symptoms.

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 in recently admitted psychiatric in-patients: a case-control study

BACKGROUND

Around a quarter of in-patient suicides occur within the first week of admission to psychiatric in-patient care. Little is known on the factors associated with suicide during this critical time. We aimed to identify risk factors for suicide among in-patients within the first week of admission.

METHODS

A national population-based case-control study of 107 current psychiatric in-patients in England who died by suicide within a week of admission, matched on admission date with 107 living controls.

RESULTS

Forty-two (40%) suicide cases died within the first 3 day of admission. A fifth of all suicides were on authorised leave at the time of death, but 34% were off the ward without staff agreement compared to only 1% of controls. Independent risk factors for suicide included previous self-harm, recent adverse life events, and a short (<12 months) duration of illness.

LIMITATIONS

This is a retrospective study, using clinical data mainly collected from case records. Clinicians were not blind to case/control status.

CONCLUSIONS

The first few days of admission should be recognised as the period of highest risk. Careful risk evaluation is needed at this time, particularly in those with recent illness onset or previous suicide attempts. Knowledge of life events experienced before admission should be incorporated into risk assessments. Improvements to the ward environment to lessen the distress of an admission may be an important preventative measure. Protocols may require adapting to improve the safety of those on agreed leave, and prevent absconding through increased vigilance and closer observation of ward exits.

Clinical risk assessment rating and all-cause mortality in secondary mental healthcare: the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLAM BRC) Case Register

BACKGROUND

Mental disorders are widely recognized to be associated with increased risk of all-cause mortality. However, the extent to which highest-risk groups for mortality overlap with those viewed with highest concern by mental health services is less clear. The aim of the study was to investigate clinical risk assessment ratings for suicide, violence and self-neglect in relation to all-cause mortality among people receiving secondary mental healthcare.

METHOD

A total of 9234 subjects over the age of 15 years were identified from the South London and Maudsley Biomedical Research Centre Case Register who had received a second tier structured risk assessment in the course of their clinical care. A cohort analysis was carried out. Total scores for three risk assessment clusters (suicide, violence and self-neglect) were calculated and Cox regression models used to assess survival from first assessment.

RESULTS

A total of 234 deaths had occurred over an average 9.4-month follow-up period. Mortality was relatively high for the cohort overall in relation to national norms [standardized mortality ratio 3.23, 95% confidence interval (CI) 2.83-3.67] but not in relation to other mental health service users with similar diagnoses. Only the score for the self-neglect cluster predicted mortality [hazard ratio (HR) per unit increase 1.14, 95% CI 1.04-1.24] with null findings for assessed risk of suicide or violence (HRs per unit increase 1.00 and 1.06 respectively).

CONCLUSIONS

Level of clinician-appraised risk of self-neglect, but not of suicide or violence, predicted all-cause mortality among people receiving specific assessment of risk in a secondary mental health service.

An Emic Perspective on the Dynamics of Non-Fatal Suicidal Behaviour in a Sample of South African Indian Women

We aimed to obtain an emic perspective on the dynamics of non-fatal suicidal behaviour in a high risk population group in South African, viz. adolescent females of Indian origin. Interviews were conducted with 10 respondents admitted to a state hospital in the greater Durban area, following their intentional overdose of prescription medication. Interviews were tape recorded, transcribed, and thematically analysed in an attempt to identify influences on suicidal behaviour. Intrapersonal influences on suicidal behaviour included poor communication and problem-solving skills. Interpersonal influences included family conflict, rigid and inflexible parental attitudes, a family history of attempted or completed suicide and high parental expectations. Socio-cultural influences related largely to conflicting social roles and values in the context of contemporary acculturation pressures. The study findings are discussed in terms of their implications for prevention and future research.

Factors predictive of ten-year mortality in severe anorexia nervosa patients

OBJECTIVE

Little is known concerning mortality and predictive factors for anorexia nervosa in-patients. This study aimed to establish mortality rates and identify predictors in a large sample of adults through a 10-year post in-patient treatment follow-up.

METHOD

Vital status was established for 601 anorexia nervosa (DSM-IV) consecutive in-patients with initial evaluation at admission. Standardized mortality ratio (SMR) was calculated. Cox analyses for hypothesized predictors of mortality were performed.

RESULTS

Forty deaths were recorded. SMR was 10.6 [CI 95% (7.6-14.4)]. Six factors at admission were associated with death: older age, longer eating disorder duration, history of suicide attempt, diuretic use, intensity of eating disorder symptoms, and desired body mass index at admission.

CONCLUSION

Anorexia nervosa in-patients are at high risk of death. This risk can be predicted by both chronicity and seriousness of illness at hospitalization. These elements should be considered as warnings to adapt care provision and could be targeted by treatment.