(Sept. 7, 2016) Suicide risk - "danger to self," as it is often called in governing laws - is one of the universal grounds for involuntary hospitalization in the United States. Both the legal and clinical worlds assume that, when a person is threatening to take his or her own life, hospital care with close supervision, clinical support and removal from contributing stressors and triggers can be life-saving.
What happens when those beds go away? As the nation observes National Suicide Prevention Week, it is a question worth adding to all the others that suicide poses.
Suicide Trends
Since 1999, the adjusted rate at which Americans killed themselves increased 24%, with the rate of growth accelerating after 2006. The increase affected every demographic group except black males. In 2014, the Centers for Disease Control reports, nearly 43,000 people died of suicide in the United States, 7,000 more than were killed in car accidents. Suicide is the 10th leading cause of death in the nation, the 2nd among 15 to 24 year olds and the leading cause of death in jails and prisons.
At the same time the suicide rate was rising, the number of psychiatric beds in the United States was plummeting. By early 2016, there were 37,679 last-resort beds left in a nation where an estimated 3.8 million people with schizophrenia or severe bipolar disorder are untreated on any given day. Psychiatric bed numbers also were falling in private facilities.
Such shrinkage limits both the number of patients who can be served in psychiatric hospitals and how long they are allowed to stay before discharge. Unsurprisingly, length of stay has shrunk in tandem the bed numbers, from an average of 18 days in 1998 to 5.5 days by 2011.
The relationship between rising suicide rates and shrinking bed numbers is largely TBD: to be determined. In "Does deinstitutionalization increase suicide?" Yoon and Bruckner made a "crude calculation" that eliminating 1 public bed per 100,000 people in the United States in 1998 translated into approximately 45 additional suicides. They said bed reductions may relate to suicide rates by influencing whether hospital access is available in times of need and whether unserved people self-medicate with drugs or alcohol when they don't get timely intervention.
But the subject is considered controversial, study of the relationship is limited, and much of what has been published is in journal editorials and letters to the editor.
We do know that suicide risk skyrockets immediately following hospitalization. In the first 28 days after hospital discharge, the suicide rate has been reported to be more than 200 times greater for men and more than 100 times greater for women than that for the general population. The connection between hospital stay and suicide is not well-understood, but hospital stays too short to restore stability in people with bipolar disorder or depression are considered likely to be a factor. A study that reported on the patterns of suicide and hospital length stays from 1976 to 1995 in a large Swedish county led the authors to conclude "the reduction of beds is the most probable explanation for the rising mortality."
Risk and Risk Factors
Schizophrenia and bipolar disorder are risk factors for suicide, which kills an estimated 5% of those with schizophrenia and 10% to 15% of those with bipolar. The likelihood of attempted suicide is much higher, with some studies reporting that up to 50% of individuals with the most severe mental illnesses attempt to take their own lives at some point. Most are not receiving treatment for their illness when they die.
Among people in these populations, depressive symptoms, substance abuse, awareness of illness (i.e., absence of anosognosia), a history of violent behavior and poor adherence to medication are additional risks. Essentially unexamined, the role of hospital bed access and length of stay remains unknown.
Many recommendations have been advanced to reduce the number of people who take their own lives each year. Improved post-discharge treatment and community support, family education and others are proposed and sometimes implemented. However, the rate keeps rising.
In the search for strategies to prevent suicide, closer examination of the role that psychiatric hospitalization plays deserves closer study.
Doris A. Fuller
Chief of Research and Public Affairs
References:
- Centers for Disease Control and Prevention. (April 2016.) Increase in suicide in the United States, 1999-2014.
- Fuller DA et al. (June 2016). Going, going, gone: Trends and consequences of eliminating state psychiatric beds, 2016. Treatment Advocacy Center.
- Yoon, J. and T. Bruckner. (August 2009). Does deinstitutionalization increase suicide? Health Services Research.
- Huntley, DA et al. (1998). Predicting length of stay in an acute psychiatric hospital. Psychiatric Services.
- Glick, ID et al. (2011). Inpatient psychiatric care in the 21st century: The need for reform. Psychiatric Services.
- Goldacre, M. (1993). Suicide after discharge from psychiatric inpatient care. The Lancet.
- Osby U. et al. (August 2000). Time trends in schizophrenia mortality in Stockholm County, Sweden: Cohort study. British Journal of Medicine.
Next Week: Introducing Updated Background on SMI Issues
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