All Patients at Risk for Suicide After Psychiatric Facility Discharge, Study Finds

All patients are at risk for suicide after they are discharged from psychiatric facilities, not just patients who were admitted for suicidal thoughts or behaviors.

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That is the finding from 50 years of data synthesized in an international meta-analysis published online in JAMA Psychiatry on May 31.

The authors reported that the suicide rate of patients in the first three months after discharge was approximately 100 times the global suicide rate of 11.4 per 100,000 patients per year in 2012. Patients admitted with suicidal thoughts and behaviors had rates nearly 200 times the global rate. Even many years after they were discharged, previous psychiatric inpatients had suicide rates that were approximately 30 times higher than typical global rates, according to the authors.

“Our findings better support the views of authors who believe in a more universal approach to suicide prevention that might focus on periods of high risk but that extends for periods of years,” wrote Daniel Thomas Chung of the University of New South Wales in Australia and colleagues.

The meta-analysis looked at 100 English-language, peer-reviewed studies published from January 1, 1946, to May 1, 2016. They included 183 patient samples and more than 17,000 deaths by suicide.

The authors reported that the suicide rate was highest within three months after discharge and among patients admitted with suicidal ideas or behaviors. Pooled suicide rates per 100,000 patient-years were 654 for studies with follow-up periods of three months to one year, 494 for studies with follow-up periods of one to five years, 366 for studies with follow-up periods of five to 10 years, and 277 for studies with follow-up periods longer than 10 years. (A pooled estimate postdischarge suicide rate is the rate that summarizes the earlier studies; it is similar to an average. Each study is weighted depending on the sample size.)

The high suicide rate of discharged patients might be attributable to multiple factors, according to the authors. Among them are changing legal and other criteria for admission. Co-author Matthew Michael Large, M.B.B.S., D.Med.Sci., told Psychiatric News that since the mid-1970s, danger to self or others is cause for an involuntary admission to a psychiatric facility in many jurisdictions. He noted that in an “era of declining bed numbers over the last 30 years, the threshold for admission has gone up.”

Other factors included shorter lengths of inpatient treatment, increased prevalence of substance use, publication bias in favor of recent studies from regions with a higher suicide rate, and greater acuity of illness among those admitted in the deinstitutionalization era. Large said that deinstitutionalization has occurred in almost all of the high-income countries in the meta-analysis including the United States, Canada, Australia, and the United Kingdom.

Early intervention is crucial to preventing suicide among discharged psychiatric patients. “Efforts aimed at suicide prevention should start while patients are in the hospital, and the period shortly after discharge should be a time of increased clinical focus,” the authors wrote. However, since the study also suggested that previously admitted patients, particularly those with prior suicidality, remain at a markedly elevated risk of suicide for years, they should be a focus of efforts to decrease suicide in the community, they added.

The suicide rate in the United States has continually increased in the past decade. In contrast, the rates of eight of the other 10 leading causes of death in the United States have declined in recent years, wrote Mark Olfson, M.D., M.P.H., a professor of psychiatry at Columbia University School of Medicine, in an accompanying editorial. He was not involved in the meta-analysis.

“The national increase in suicide rate brings renewed urgency to suicide research and implementation of effective suicide prevention programs,” he wrote.

Olfson noted that in the United States, transitions from inpatient to outpatient care are often “poorly managed” and suggested that the connection between inpatient and outpatient psychiatric services be strengthened to help lower suicide risk during the first months when the risk is highest.

“Only about half of psychiatric inpatients receive any outpatient care during the first week after hospital discharge, and only about two-thirds receive any outpatient mental health care during the first month,” he wrote.

An observational study in the United Kingdom found that implementing a policy of following up with patients within seven days of discharge was associated with a “significant decrease in suicide during the three months after hospital discharge,” Olfson wrote.

He suggested that to make meaningful progress in reducing the rate of suicide, “system-wide reforms in monitoring patients after hospital discharge will likely need to be complemented with traditional suicide-specific patient interventions.” Among the traditional suicide-specific interventions are crisis-intervention lines, crisis-counseling services, and on-call mental health services.

Related literature shows that “time-limited interventions” including home visits, social support, and having care coordinators accompany recently discharged psychiatric patients to outpatient appointments “improves continuity of care and reduces the risk of early hospital readmission,” Olfson told Psychiatric News.

“The new findings will hopefully build support among public and private payers for reimbursement of transitional care services during the high-risk period following psychiatric hospital discharge,” he said. ■