Short-Term Suicide Risk For Discharged Psychiatric Hospital Patients

Researchers have found that after being discharged from an inpatient psychiatric hospital, patients with depression were at a particularly high risk of short-term suicide. Those with schizophrenia or bipolar disorder were also at an incrementally increased risk, as were those who were hospitalized for a psychiatric condition but had not had recent contact with the outpatient health care system. The findings were published in JAMA Psychiatry.¹

Because much of the previous research in this subject area has focused on the suicide risk of one disorder, little is known about risk of suicide across pooled psychiatric disorders or in general medical conditions with psychiatric comorbidities.

To examine short-term suicide risk in these areas, Mark Olfson, MD, MPH, from the New York State Psychiatric Institute, Department of Psychiatry at Columbia University in New York and colleagues examined the risk of suicide in 1 861 194 adults in the Medicaid program (27% men; 73% women; mean [SD] age, 35.4 [13.1] years), including 770 643 in the mental disorder cohorts and 1 090 551 in the non-mental disorder cohort, during 90 days after hospital discharge.

The substance use disorder cohort had the lowest percentage of young adults and the highest percentage of men, and the non-mental disorder cohort had the highest percentage of young adults (aged 18-34 years) and women.

The researchers found that the short-term suicide rate of the cohort with any mental disorder was 178.3 per 100 000 person-years, compared with a demographically matched suicide rate of 12.5 per 100 000 person-years in the US general population.

“During the first 90 days after psychiatric hospital discharge, suicide risk among women and men was highest for those with depressive and bipolar disorders, followed by schizophrenia and substance use disorder,” the authors wrote. “Demographic risk factors for suicide among recently discharged psychiatric inpatients resembled suicide risk factors in the general US population. In both populations, the risk is greater for men than women, older than younger adults, and white than black or Hispanic individuals.”²

The researchers also found that:

• Men, adults aged 45 to 64 years, and white psychiatric inpatients also had an increased short-term risk of suicide.
• Psychiatric inpatients who had not received any outpatient health care in the 6 months before they were admitted to the hospital were also at an increased short-term risk of suicide.
• A history of recent self-harm was associated with a short-term risk of suicide, although this association was reduced after controlling for demographic and other clinical characteristics. The authors noted that underreporting of self-harm in administrative data may have accounted for this reduced association.

“Under financial pressures to shorten inpatient stays, inpatient psychiatrists commonly face clinical uncertainties in determining when patients are no longer at short-term risk for suicide,” the authors wrote. This study provides insight into which patients may need to be monitored with more caution.

The researchers also noted, however, that the low absolute risk of suicide limits these types of studies’ ability to make predictions based on clinical variables, which highlights the difficulty of predicting suicide based on clinical characteristics.

 The study’s limitations include:

• An inability to verify the diagnoses in the Medicaid claims data
• The possibility that results may have been different in a population of privately insured or uninsured patients
• A lack of information about factors such as family history of suicide, lifetime personal history of attempted suicide, proximal stressful life events, self-harm events, and access to lethal means
• The possibility that suicide was underrepresented in death certificates due to stigma, low autopsy rates, or emigration
• The possibility that suicide mortality patterns in 2001 to 2007 may have changed in recent years, or that suicide rates in older populations may be different

“[The patterns in this study] suggest that complex psychopathologic diagnoses with prominent depressive features, especially among adults who are not strongly tied into a system of care, may pose a particularly high risk,” the study authors concluded.

References

1. Olfson M, Wall M, Wang S. Short-term suicide risk after psychiatric hospital discharge. JAMA Psychiatry. 2016;73(11):1119-1126. doi:10.1001/jamapsychiatry.2016.2035.

2. Parks SE, Johnson LL, McDaniel DD, Gladden M. Centers for Disease Control and Prevention (CDC). Surveillance for violent deaths: National Violent Death Reporting System, 16 states, 2010. MMWR Surveill Summ. 2014;63(1):1-33.