Timely Outpatient Care May Help Reduce Suicide Risk in Youths

After a psychiatric hospitalization, follow-up care within 7 days of discharge was found to be associated with reduced suicide risk, according to the results of a study published in JAMA Network Open. However, several barriers may delay follow-up care.

Risk for suicide is highest immediately after discharge from a psychiatric hospital and remains high for months and even years after discharge. The National Committee on Quality Assurance and the Centers for Medicare & Medicaid Services recommend follow-up within 7 and 30 days after discharge following psychiatric hospitalization.

The study authors wanted empirical evidence to support the association of timely outpatient care with lower suicide risk. At present, only half of psychiatric inpatients receive follow-up care within 7 days of discharge. The study authors also wanted to explore the factors associated with delayed follow-up care.

A population-based, retrospective, longitudinal cohort study evaluated Medicaid claims data of 139,694 young adults aged 10 to 18 years from 33 US states. The cohorts were admitted to a psychiatric hospital between January 1, 2009, and December 31, 2013. Readmissions were excluded. The claims data were linked to the National Death Index.

The investigators found that 56.5% of patients received a mental health visit within 7 days of hospital discharge. No statistically significant difference in receipt of follow-up care was reported for patients discharged with a primary diagnosis of depression vs those with bipolar or other mood disorders.

Compared with patients diagnosed with depression, those with a substance use disorder had 65% lower odds of receiving timely follow-up care and those with other mental health disorders (eg, anxiety) had 46% lower odds. Black, Hispanic, and other racial/ethnic groups were less likely to receive timely follow-up care compared with White youths. The study also evaluated follow-up care relative to poverty, insurance type, disability, history of psychiatric hospitalization, and length of stay, among other factors.

Of all patients evaluated, 22 died by suicide within 6 months of discharge, 8 of whom received follow-up mental health care within 7 days of discharge.

Concerning limitations, the analyses focused on Medicaid-enrolled patients and may not be associable to privately insured or uninsured inpatients with psychiatric disorders. In addition, the use of claims precluded examination of other important factors that may affect receipt of follow-up care among children and adolescents, such as the use of psychotropic medication, family functioning and support, caretaker perception of burden of care, and intervention strategies that hospital staff use to link patients to outpatient care.

The researchers were also not able to assess the availability of services or the adequacy or effectiveness of services that the patients received. Limited outcome events are common problems in studies of this type, and the small number of suicide deaths may have limited statistical power. Finally, results may not generalize to the small proportion of patients who were excluded owing to psychiatric readmission during the study period. It is possible that the subgroup of readmitted youths may represent a higher-risk group for suicide and residual confounding may have accounted for the tendency for patients who received follow-up care to have a lower odds of suicide.

Considering that 43.5% of the patients studied did not receive timely follow-up care, the study authors suggested quality improvement efforts and interventions to improve inpatient to outpatient care to reduce suicide risk. Suggestions include “minimizing wait time to the first appointment, having inpatient staff clarify expectations about the role of aftercare, making appointments for patients with the aftercare agency, and reaching out techniques (eg, having the aftercare agency contact patients before the appointment and use of telephone prompts, reminder letters, and a referral coordinator),” the authors stated.

Reference

Fontanella CA, Warner LA, Steelesmith DL, Brock G, Bridge JA, Campo JV. Association of timely outpatient mental health services for youths after psychiatric hospitalization with risk of death by suicide.  JAMA Netw Open. 2020;3(8):e2012887. doi:10.1001/jamanetworkopen.2020.12887