The risk for suicide is strikingly elevated immediately after discharge from a psychiatric facility and remains elevated years later, according to a synthesis of more than 50 years of research on postdischarge suicide rates.
Results from a large meta-analysis show that the postdischarge suicide rate was roughly 100 times the global suicide rate during the first 3 months following discharge, and patients admitted with suicidal thoughts or behaviors had rates almost 200 times the global rate, the researchers report.
This analysis “clarifies the extent and duration of the increased risk of suicide post discharge, finding a significantly higher and much more enduring risk than was generally believed,” Matthew Michael Large, MBBS, of the University of New South Wales, Australia, told Medscape Medical News. “Having been a psychiatric inpatient seems to be the single strongest suicide risk factor.
“Clinicians should not assume that discharged patients who seem to be at low risk of suicide on clinical grounds are not in need of ongoing support and assistance. Health systems need to be designed to facilitate long-term care for discharged patients,” added Dr Large.
The study was published online May 31 in JAMA Psychiatry.
Ongoing Prevention Needed
The research team quantified rates of suicide after discharge from psychiatric care in their analysis of 100 studies with 183 patient samples reporting 17,857 suicides during roughly 4.7 million person-years.
The pooled estimate discharge suicide rate was 484 per 100,000 person-years. The highest rate of suicides committed during the first 90 days following discharge (1132 per 100,000 person-years) were among patients admitted with suicidal thoughts or behaviors (2078 per 100,000).
The pooled suicide rates (per 100,000 person-years) were 654 in studies with follow-up from 3 months to 1 year; 494 in studies with follow-up from 1 to 5 years; 366 in studies with follow-up lasting 5 to 10 years; and 277 in studies with follow-up longer than 10 years, the authors report.
For comparison, the World Health Organization estimated that the global suicide rate was 11.4 per 100,000 person-years in 2012; the US suicide death rate was 13.4 per 100,000 population in 2014.
The analysis suggests that the suicide rate among discharged patients has not decreased in the past 50 years. “This is a disturbing finding considering the increase in community psychiatry and the availability of a range of new treatments during this period,” the authors write.
This study, the investigators note, “suggests that previously admitted patients, particularly those with prior suicidality, remain at a markedly elevated risk of suicide for years and should be a focus of efforts to decrease suicide in the community.”
“Disturbing Trend”
Suicide has proven to be a “stubbornly difficult threat to health,” writes Mark Olfson, MD, MPH, of the Department of Psychiatry, Columbia University and New York State Psychiatric Institute in New York City, in a linked editorial.
“Despite clinical and public health efforts aimed at preventing suicide, the suicide rate in the United States has steadily increased over the past decade,” he notes. “This disturbing trend 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. The national increase in suicide rate brings renewed urgency to suicide research and implementation of effective suicide prevention programs.”
The new analysis, said Dr Olfson, provides a clear clinical message: “universal and continuing suicide prevention interventions are needed for patients after psychiatric hospital discharge, with a higher level of clinical monitoring and support for patients during the first few months after hospital discharge and for patients with a history of suicidal behavior.”
To make meaningful progress, “system-wide reforms in monitoring patients after hospital discharge will likely need to be complemented with traditional suicide-specific patient interventions, such as safety planning, crisis lines, crisis counseling services, and on-call mental health services,” Dr Olfson says.
“A greater appreciation of the enduring elevated risk of psychiatric inpatients after discharge might help build support for the clinical resources to reduce the unacceptably large number of individuals who die by suicide each year,” Dr Olfson concludes.
The study had no commercial funding. The authors have disclosed no relevant financial relationships.
JAMA Psychiatry. Published online May 31, 2017. Full text, Editorial
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