Early Postdischarge Period Linked to Very High Suicide Risk

Deborah Brauser

April 12, 2013

Psychiatric inpatients are at extreme risk for suicide in the period immediately following discharge, but high-quality aftercare may be protective, new research suggests.

A retrospective case-control study showed that 55% of 100 patients in England with psychiatric illness who died by suicide did so within the first week of being discharged — and nearly half of those died before their first follow-up treatment appointment.

Factors associated with increased suicide risk during this period included hospitalization of less than 1 week, recent adverse events, older age, and comorbid psychiatric disorders. Factors associated with decreased risk included patients receiving enhanced aftercare.

"Discharged patients viewed as being at high risk of suicide require immediate community follow-up," the investigators, led by Harriet Bickley, from the Center for Mental Health and Risk at the University of Manchester in the United Kingdom, write.

In addition, the finding that detrimental life experiences are a significant contributor to increased risk indicates that "mental health clinicians need to be aware of the circumstances into which patients are being discharged," they add.

Provision of enhanced levels of aftercare, such as programs using the Care Program Approach (CPA), is also important. CPA is a community mental health services delivery system in England and Wales that includes supervision by a care coordinator (usually a psychiatric nurse or social worker) and regular multidisciplinary case reviews.

"Our results are the first, to our knowledge, to suggest that this higher level of aftercare may be independently protective," write the investigators.

The study was published online April 1 in Psychiatric Services.

Identifying Risk, Protective Factors

Although previous research has shown a significant risk for suicide completion throughout the first year after patients have been discharged from hospitalization, the investigators note that the period immediately after release is the time of highest risk.

"Our previous work identifying risk factors for suicide in the postdischarge period found that 43% died in the first month," they write.

The investigators note that to their knowledge, no national, controlled studies have been conducted that specifically assess suicide risk in the 2-week postdischarge period.

"Yet, identifying predictors of poor outcome soon after a psychiatric hospitalization may help service providers to improve discharge planning and care arrangements, thereby potentially reducing the incidence rate," write the researchers.

The current study's aim was to identify both clinical and psychosocial risk and protective factors, including differences in type and amount of aftercare received, during the early postdischarge period.

The investigators examined data from the National Confidential Inquiry Into Suicide by People With Mental Illness survey on 100 adults in England between the ages of 18 and 65 years (mean age, 44.5 years; 62% men) who had completed suicide within 2 weeks of being fully discharged from an inpatient facility between January 2004 and December 2006.

These patients were matched with 100 psychiatric patients who were discharged at the same time but who did not commit suicide (control group; mean age, 39.5 years; 50% men).

Clinician-completed suicide questionnaires reported sociodemographics, clinical history, information about inpatient admissions and discharges, details about enhanced aftercare under the CPA, and details of the suicide.

Significant Risk Factors

Results showed that the top 3 most common methods of suicide completion were hanging (n = 39), self-poisoning (n = 23), and jumping in front of a vehicle or from a height (n = 19). Although the most common primary psychiatric diagnosis was major affective disorder (n = 35), 67 of the patients also had secondary diagnoses.

Of the 55 suicides that took place within the first week of being discharged, the second day after discharge had the most deaths (n = 13).

Significant predictors of suicide within 2 weeks of discharge included age 40 years or older (P = .03), history of self-harm (P < .01), any secondary psychiatric diagnosis (P < .01), adverse life events within the past 3 months (P < .01), illness onset in the past year (P = .03), and an index hospitalization of less than 1 week (P = .03).

"Mental health services should be mindful of discharging patients after a short admission," write the investigators.

Significantly fewer of the patients who died by suicide were receiving CPA care compared with the control patients (P = .02).

Although past studies have shown that even low-intensity contact, such as through postcards and telephone calls, may be helpful, "our results have highlighted the importance of face-to-face contact with patients after discharge, which may be protective," write the researchers.

"The period after hospital discharge should be a time of recovery, not increased suicide risk," they add.

The study was funded by the United Kingdom National Patient Safety Agency. The study authors have reported no relevant financial relationships.

Psychiatr Serv. Published online April 1, 2013. Abstract

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