(June 13, 2017) Suicide risk has long been known to rise following psychiatric hospitalization for reasons that are unknown. Now a meta-analysis of suicide literature published in English worldwide from 1946 through mid-2016 has quantified the magnitude of the effect. The results are grim, with evidence indicating they may be getting grimmer.
The World Health Organization (WHO) estimates the worldwide suicide rate without differentiation by age was 11.4 deaths per 100,000 person-years in 2012. The meta-analysis of 100 unique studies on five continents found an overall suicide rate of 484 deaths per 100,000 person-years following psychiatric hospitalization - more than 44 times the WHO estimate.
Heightened risk was consistent across nations, age groups, diagnoses, duration of the hospitalization and other variables.
Trends in Suicide Risk
The magnitude of increased risk appeared from the analysis to be growing. From 2005-2016, the overall suicide rate following hospital discharge was 672 deaths per person-year. It was somewhat lower (656 deaths) from 1995-2014 but substantially lower (404 deaths) from 1984-1995 and in other earlier periods.
"This is a disturbing finding considering the increase in community psychiatry and the availability of a range of new treatments during this period," Daniel Thomas Chung and colleagues write in the May 31, 2017, issue of JAMA Psychiatry.
Risk was highest immediately followed discharge and diminished over time but was found to endure for many years following hospitalization.
The overall suicide rate within three months of discharge was reported at 1,132 deaths per 100,000 person-years - almost 100 times greater than the global rate. The rate per 100,000 person-years decreased following discharge as follows but remained high:
- 654 deaths from 3 to 12 months (57 times global rate)
- 494 deaths from 1 to 5 years (43 times global rate)
- 366 deaths from 5 to 10 years (32 times global rate)
- 277 deaths after 10 years (24 times global rate)
A related JAMA Psychiatry editorial in the same issue called the findings a "disturbing trend that stands in sharp contrast with 8 of the other 10 leading causes of death in the United States, the rates of which have substantially decreased in recent years."
Risk Factors
While suicide risk rose across all hospitalized groups, it was found to be lower among discharged adolescents, adults over 65 years old, patients hospitalized for the first time and patients discharged from a long-term psychiatric hospitalization. The meta-analysis illuminated that patients with psychosis, affective disorders including bipolar disorder and mixed diagnoses had similar suicide rates; virtually all mental health disorders are associated with increased likelihood of death by suicide, according to suicide literature.
The mechanisms that lead some individuals to take their own lives and spare others are unknown, and the meta-analysis provided no explanations.
"An increase in the suicide rate of admitted and discharged patients might be attributable to multiple factors, including changing legal and other criteria for admission, shorter lengths of inpatient treatment, increased prevalence of substance use and a greater acuity of illness among those admitted in the era of deinstitutionalization," the authors speculated.
In part because of heightened suicide risk, patient follow-up after hospital discharge has become a subject of considerable research interest in recent years.
A January 2017 report by Thomas E. Smith and colleagues examined Medicaid claims associated with more than 17,000 psychiatric hospitalization discharges in New York from mid-2012 to mid-2013 to assess whether discharge planning in the hospital increased the timing and likelihood that patients would receive follow-up care in the community.
The study found a significant association between the number of discharge planning practices hospitals used and the speed to the first outpatient visit. However, while most of the hospitals in the study reported contacting the outpatient providers of their patients, scheduling follow-up outpatient appointments or forwarding discharge summaries for their patients, barely one-third of discharged adults and less than one-half of discharged adolescents were seen by a mental healthcare provider within seven days of leaving the hospital, considered a period of extreme suicide risk.
A bare majority of adults (55%) and nearly two-thirds of adolescents (65%) were seen by providers within 30 days of discharge.
Discharge planning and follow-up in the community are widely accepted as best practices throughout medicine and commonly proposed as methods for reducing suicide. Their efficacy, like the causes of suicide itself, remains unknown. Among other causes of suicide under investigation are immune response, described in our May 9 Research Weekly.
Doris A. Fuller
Chief of Research and Public Affairs
References:
- Chung, D.T., et al. (May 31, 2017). Suicide rates after discharge from psychiatric facilities: A systematic review and meta-analysis. JAMA Psychiatry.
- Olfson, M. (May 31, 2017). Suicide risk after psychiatric discharge. JAMA Psychiatry.
- Smith, T.E., et al. (January 2017). Psychiatric inpatient discharge planning practices and attendance at aftercare appointments. Psychiatric Services.
- Research Weekly. (May 9, 2017). Suicide attempts and immune response. Treatment Advocacy Center.
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Research Weekly is a summary published as a public service of the Treatment Advocacy Center and does not necessarily reflect the findings or positions of the organization or its staff. Full access to research summarized may require a fee or paid subscription to the publications.
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