0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Editorial |

Postdischarge Suicides Nightmare and Disgrace FREE ONLINE FIRST

Merete Nordentoft, DMSc1,2,3; Annette Erlangsen, PhD3,4,5; Trine Madsen, PhD3
[+] Author Affiliations
1Research Unit, Mental Health Centre Copenhagen, Copenhagen, Denmark
2Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
3Danish Research Institute for Suicide Prevention, Mental Health Centre Copenhagen, Copenhagen, Denmark
4Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
5Institute of Regional Health Research, University of Southern Denmark, Odense
JAMA Psychiatry. Published online September 21, 2016. doi:10.1001/jamapsychiatry.2016.2010
Text Size: A A A
Published online

It is devastating when a person who has recently been discharged from a psychiatric hospital dies by suicide. The act demonstrates the patient’s suffering, lack of hope, disappointment, and despair. Family members and next of kin are hit by sorrow and crisis. Often they will blame themselves or feel that the psychiatric services were inadequate. For the psychiatrist who treated the patient, a postdischarge suicide can be associated with self-blame and the risk for being accused of misconduct.

The study by Olfson and coauthors1 in this issue of JAMA Psychiatry has taken advantage of longitudinal cohort data on psychiatric inpatients obtained from the Centers for Medicare & Medicaid Services. The study is important because it emphasizes the critically high risk for suicide associated with recent discharge from psychiatric inpatient units. The findings are in line with those of previous studies from other countries24 and demand close attention: recently discharged psychiatric patients show one of the highest suicide rates of any identified risk group. The present study extends existing knowledge by identifying “absence of any outpatient health care in the 6 months preceding hospital admission” as associated with postdischarge suicide and by showing elevated risks for postdischarge suicide among patients treated for schizophrenia and bipolar disorder in outpatient settings shortly before hospitalization.

Olfson and coauthors found that the suicide rate among patients with the diagnosis of any mental disorder in the 3 months after discharge was 178.3 per 100 000 person-years, equal to 44 suicides within the first 3 months per 100 000 discharges (based on 338 suicides and 770 643 discharged patients as reported by Olfson et al) during 2001 to 2007. A rate of 178.3 per 100 000 person-years is considerably higher than the suicide rate of 12.5 per 100 000 person-years reported for the demographically matched US general population.1 However, the proportion of 44 suicides per 100 000 discharges is substantially lower than similar figures reported by large population studies abroad. A suicide rate during the first 3 months after discharge of 166 per 100 000 discharges was found in England,5 whereas a Danish study reported 204 suicides per 100 000 discharges.6 Possible explanations for the lower risk noted in the US study could be differences in aftercare or differences in the studied populations; although the European studies included all discharged patients, the US study was restricted to first-time admissions. Given that the risk for suicide increases with the number of psychiatric admissions,2,7 it is plausible that those readmitted represent a more severely ill group of patients who also have a higher risk for suicide after discharge. Furthermore, the US sample did not cover persons who were privately insured or uninsured (ie, not eligible for Medicaid services). Access to mental health care in the United States largely depends on insurance coverage, and findings indicate that persons with no insurance but a mental disorder are less likely than all types of insurance holders to see a health care professional.8

Apart from mental disorders, a history of deliberate self-harm (DSH) has been linked to an elevated risk for suicide after discharge.912 The adjusted hazards ratios of Olfson and coauthors regarding recent DSH as a predictor of short-term postdischarge suicide were not significant. However, only 1.9% of patients admitted for the first time reported DSH, whereas a Danish national cohort study reported a DSH episode in 15% of patients within the year before admission,13 and 10% to 15% of English psychiatric inpatients reported episodes of self-harm before admission.10,11 The lower prevalence of recent DSH among US patients might explain the relatively lower postdischarge suicide rate in the study by Olfson and coauthors. On the other hand, as suggested by the authors, a potential underreporting of DSH could also offer an explanation for why DSH was not a significant predictor.

Concerns have been voiced that deinstitutionalization and decentralization during recent decades within the psychiatric services may have led to an increase in postdischarge suicide rates. Different trends have been observed in northern European countries; a decreasing trend in the postdischarge suicide rate was found in Denmark6,14 and Finland,15 whereas an increasing rate was noted in England.5 Future analyses of US data might address the change of postdischarge suicide risk over time.

Psychiatric patients should not be considered cured at the time of discharge. They are still ill, many of their symptoms continue, treatment is ongoing, and their need for care remains. Many of these patients remain at increased risk for suicide. It is, therefore, very important to carefully plan and initiate referrals for aftercare. Ideally, outpatient treatment should be introduced before discharge, so that the patient is familiar with the persons who will care for them after discharge. In the week immediately after discharge, the risk for suicide is at its highest, which underscores the need for establishing contact and arranging an appointment to outpatient care ahead of discharge.

Assessment of suicide risk should be carefully evaluated before discharge. It must be performed in a flexible and caring manner, in an environment that secures privacy. Debate is ongoing whether risk assessments are valid. Although setting up an algorithm for the exact calculation of suicide risk will never be possible, checklists or risk scales may provide guidance to which items ought to be covered in the conversation. The low predictive value of suicide risk, that is, the lack of certainty in the prediction, has often been pointed out. Evaluation of suicide risk is not like a weather forecast; as opposed to the weather, risk for suicide can actually be addressed in and changed by interventions. This fact makes evaluations of the effectiveness of risk assessments challenging. To our knowledge, no studies have compared systematic semistructured evaluations of suicidal risk with standard procedures.

Risk assessments performed in the clinic shortly ahead of discharge may fall short of drawing conditions linked to the postdischarge situation into consideration. Although envisioning the challenges facing the patient after discharge might be difficult, it is pertinent to keep in mind that most patients are discharged back into challenging situations that might threaten the newly achieved stability. Patients are at times discharged into the same chaotic social situation of unpaid bills, a messy home environment, friends inviting them for a drink, a spouse who is still angry, and lack of possibilities of getting back to work, among others. Thus, we cannot merely consider the patient’s suicidal state while being in a protected hospital environment; we should also consider whether suicidal thoughts might reappear once the angry ex-spouse knocks at the door at 11 pm the next evening.

A recent systematic review found support for community-based interventions directed at people with mental disorders, through intensive case management or mental health teams.16 Although an appealing idea, a 7-day follow-up with discharged patients was not linked to an observable decline in the suicide rate of mental health care users. Neither were assertive outreach teams, which potentially could reach out to postdischarge patients.17

When patients are most vulnerable, we need to provide responsible care, despite budget restrictions. This ensures that clinicians are satisfied with their efforts and patients are comfortable with their psychiatric services.

ARTICLE INFORMATION

Corresponding Author: Merete Nordentoft, DMSc, Research Unit, Mental Health Centre Copenhagen, Kildegaardsvej 28, Entrance 15, 2900 Hellerup, Denmark (mn@dadlnet.dk).

Published Online: September 21, 2016. doi:10.1001/jamapsychiatry.2016.2010.

Conflict of Interest Disclosures: None reported.

REFERENCES

Olfson  M, Wall  M, Wang  S,  et al.  Short-term suicide risk after psychiatric hospital discharge [published online September 21, 2016]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.2035
Qin  P, Nordentoft  M.  Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry. 2005;62(4):427-432.
PubMed   |  Link to Article
Meehan  J, Kapur  N, Hunt  IM,  et al.  Suicide in mental health in-patients and within 3 months of discharge: national clinical survey. Br J Psychiatry. 2006;188:129-134.
PubMed   |  Link to Article
Goldacre  M, Seagroatt  V, Hawton  K.  Suicide after discharge from psychiatric inpatient care. Lancet. 1993;342(8866):283-286.
PubMed   |  Link to Article
Kapur  N, Hunt  IM, Windfuhr  K,  et al.  Psychiatric in-patient care and suicide in England, 1997 to 2008: a longitudinal study. Psychol Med. 2013;43(1):61-71.
PubMed   |  Link to Article
Madsen  T, Nordentoft  M.  Changes in inpatient and postdischarge suicide rates in a nationwide cohort of Danish psychiatric inpatients, 1998-2005. J Clin Psychiatry. 2013;74(12):e1190-e1194.
PubMed   |  Link to Article
Winkler  P, Mladá  K, Csémy  L, Nechanská  B, Höschl  C.  Suicides following inpatient psychiatric hospitalization: a nationwide case control study. J Affect Disord. 2015;184:164-169.
PubMed   |  Link to Article
Young  AS, Klap  R, Sherbourne  CD, Wells  KB.  The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry. 2001;58(1):55-61.
PubMed   |  Link to Article
Isometsä  E, Sund  R, Pirkola  S.  Post-discharge suicides of inpatients with bipolar disorder in Finland. Bipolar Disord. 2014;16(8):867-874.
PubMed   |  Link to Article
Hunt  IM, Kapur  N, Webb  R,  et al.  Suicide in recently discharged psychiatric patients: a case-control study. Psychol Med. 2009;39(3):443-449.
PubMed   |  Link to Article
Bickley  H, Hunt  IM, Windfuhr  K, Shaw  J, Appleby  L, Kapur  N.  Suicide within two weeks of discharge from psychiatric inpatient care: a case-control study. Psychiatr Serv. 2013;64(7):653-659.
PubMed   |  Link to Article
Madsen  T, Agerbo  E, Mortensen  PB, Nordentoft  M.  Deliberate self-harm before psychiatric admission and risk of suicide: survival in a Danish national cohort. Soc Psychiatry Psychiatr Epidemiol. 2013;48(9):1481-1489.
PubMed   |  Link to Article
Madsen  T, Agerbo  E, Mortensen  PB, Nordentoft  M.  Predictors of psychiatric inpatient suicide: a national prospective register-based study. J Clin Psychiatry. 2012;73(2):144-151.
PubMed   |  Link to Article
Qin  P, Nordentoft  M, Høyer  EH, Agerbo  E, Laursen  TM, Mortensen  PB.  Trends in suicide risk associated with hospitalized psychiatric illness: a case-control study based on Danish longitudinal registers. J Clin Psychiatry. 2006;67(12):1936-1941.
PubMed   |  Link to Article
Pirkola  S, Sohlman  B, Heilä  H, Wahlbeck  K.  Reductions in postdischarge suicide after deinstitutionalization and decentralization: a nationwide register study in Finland. Psychiatr Serv. 2007;58(2):221-226.
PubMed   |  Link to Article
Zalsman  G, Hawton  K, Wasserman  D,  et al.  Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry. 2016;3(7):646-659.
PubMed   |  Link to Article
While  D, Bickley  H, Roscoe  A,  et al.  Implementation of mental health service recommendations in England and Wales and suicide rates, 1997-2006: a cross-sectional and before-and-after observational study. Lancet. 2012;379(9820):1005-1012.
PubMed   |  Link to Article

Figures

Tables

References

Olfson  M, Wall  M, Wang  S,  et al.  Short-term suicide risk after psychiatric hospital discharge [published online September 21, 2016]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.2035
Qin  P, Nordentoft  M.  Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry. 2005;62(4):427-432.
PubMed   |  Link to Article
Meehan  J, Kapur  N, Hunt  IM,  et al.  Suicide in mental health in-patients and within 3 months of discharge: national clinical survey. Br J Psychiatry. 2006;188:129-134.
PubMed   |  Link to Article
Goldacre  M, Seagroatt  V, Hawton  K.  Suicide after discharge from psychiatric inpatient care. Lancet. 1993;342(8866):283-286.
PubMed   |  Link to Article
Kapur  N, Hunt  IM, Windfuhr  K,  et al.  Psychiatric in-patient care and suicide in England, 1997 to 2008: a longitudinal study. Psychol Med. 2013;43(1):61-71.
PubMed   |  Link to Article
Madsen  T, Nordentoft  M.  Changes in inpatient and postdischarge suicide rates in a nationwide cohort of Danish psychiatric inpatients, 1998-2005. J Clin Psychiatry. 2013;74(12):e1190-e1194.
PubMed   |  Link to Article
Winkler  P, Mladá  K, Csémy  L, Nechanská  B, Höschl  C.  Suicides following inpatient psychiatric hospitalization: a nationwide case control study. J Affect Disord. 2015;184:164-169.
PubMed   |  Link to Article
Young  AS, Klap  R, Sherbourne  CD, Wells  KB.  The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry. 2001;58(1):55-61.
PubMed   |  Link to Article
Isometsä  E, Sund  R, Pirkola  S.  Post-discharge suicides of inpatients with bipolar disorder in Finland. Bipolar Disord. 2014;16(8):867-874.
PubMed   |  Link to Article
Hunt  IM, Kapur  N, Webb  R,  et al.  Suicide in recently discharged psychiatric patients: a case-control study. Psychol Med. 2009;39(3):443-449.
PubMed   |  Link to Article
Bickley  H, Hunt  IM, Windfuhr  K, Shaw  J, Appleby  L, Kapur  N.  Suicide within two weeks of discharge from psychiatric inpatient care: a case-control study. Psychiatr Serv. 2013;64(7):653-659.
PubMed   |  Link to Article
Madsen  T, Agerbo  E, Mortensen  PB, Nordentoft  M.  Deliberate self-harm before psychiatric admission and risk of suicide: survival in a Danish national cohort. Soc Psychiatry Psychiatr Epidemiol. 2013;48(9):1481-1489.
PubMed   |  Link to Article
Madsen  T, Agerbo  E, Mortensen  PB, Nordentoft  M.  Predictors of psychiatric inpatient suicide: a national prospective register-based study. J Clin Psychiatry. 2012;73(2):144-151.
PubMed   |  Link to Article
Qin  P, Nordentoft  M, Høyer  EH, Agerbo  E, Laursen  TM, Mortensen  PB.  Trends in suicide risk associated with hospitalized psychiatric illness: a case-control study based on Danish longitudinal registers. J Clin Psychiatry. 2006;67(12):1936-1941.
PubMed   |  Link to Article
Pirkola  S, Sohlman  B, Heilä  H, Wahlbeck  K.  Reductions in postdischarge suicide after deinstitutionalization and decentralization: a nationwide register study in Finland. Psychiatr Serv. 2007;58(2):221-226.
PubMed   |  Link to Article
Zalsman  G, Hawton  K, Wasserman  D,  et al.  Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry. 2016;3(7):646-659.
PubMed   |  Link to Article
While  D, Bickley  H, Roscoe  A,  et al.  Implementation of mental health service recommendations in England and Wales and suicide rates, 1997-2006: a cross-sectional and before-and-after observational study. Lancet. 2012;379(9820):1005-1012.
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

1,429 Views
0 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
Jobs