Primary Psychiatry. 2007;14(12):67-74
Dr. Combs is acting instructor and Dr. Romm is associate clinical professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington in Seattle.
Disclosures: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.
Acknowledgments: The authors are grateful for the manuscript review and suggestions of Peter P. Roy-Byrne, MD, professor and vice-chair in the Department of Psychiatry at the University of Washington in Seattle and Chief of Psychiatry at Harborview Medical Center in Seattle.
Please direct all correspondence to: Sharon Romm, MD, Harborview Medical Center, 325 Ninth Ave, Office box number 359896, Seattle, WA 98104; Tel: 206-744-4517; E-mail: firstname.lastname@example.org.
• Although an infrequent occurrence, psychiatric inpatients are at particular risk for suicide.
• Risk factors associated with inpatient suicide are identified; however, current ability to predict who will commit suicide while in the hospital is poor.
• Precautions can be taken to reduce the risk of inpatient suicide.
• In the aftermath of suicide, one must consider the impact on family, other patients, staff, and physicians.
Suicides that occur while a patient is hospitalized are tragic events causing immense distress to relatives, peers, and professional caregivers. The prevalence of this infrequent occurrence is between 0.1% and 0.4% of all psychiatric admissions. This article reviews the literature to see if such events can be predicted and prevented; attempts to identify high-risk patients through demographics, diagnoses, medication treatments, and patient social situations; and examines the care-delivery environment such as length of stay and physical surroundings. This article also examines the means patients used to end their lives and when in their hospital course they did so. The authors ask if standard predictors are applicable to hospitalized patients, speculate on potential preventive measures, examine the effect on care providers, and explore what might ease the aftermath. Affective disorders or schizophrenia are most frequently associated with inpatient suicide. Most occur while patients are off the psychiatric unit. Suicides on-ward are usually accomplished by hanging; off-ward suicides are also often violent. Most patients denied suicidal ideation prior to the act. Factors associated with suicide in the general population are not consistently associated with inpatient suicides. Patient monitoring is not always effective. The first week of hospitalization and the days immediately after discharge are when patients are most vulnerable to end their lives. The authors conclude that the potential for suicide may be present from the initiation of hospitalization, but the ability to determine individuals at risk is, at best, poor.
Suicides are tragic events causing immense distress to relatives, peers, and professional caregivers. Taking one’s own life is often carried out in private and rarely in public. Suicides occur even less frequently while a patient is hospitalized and under the watchful eyes of care providers. Such an event carries an especially powerful emotional charge since a psychiatric inpatient unit is supposed to be a safe refuge from the destructive sequelae of mental illness. In-hospital suicides cause additional legal problems for the care delivery system and providers; the most frequent legal action involving a psychiatric service is the failure to protect patients from harming themselves.1-3
Although an infrequent occurrence, psychiatric inpatients are at particular risk for suicide.4-7 The prevalence of inpatient suicide is between 0.1% and 0.4% of all psychiatric admissions.8 This article reviews the literature pertaining to inpatient suicide to examine whether such events can be predicted and forestalled. The authors identify patients who are at especially high risk by examining demographics, diagnoses, medication treatments, and patient social situations associated with suicide. The article explores risk factors in the care-delivery environment such as length of stay and physical surroundings.1 Also examined are the means patients used to end their lives and when in their hospital course they did so. The authors question if standard predictors of suicide are applicable to hospitalized patients and speculate on potential preventive measures. Finally, the authors examine the effect on care providers and explore what might be done to ease the aftermath.
The databases of PubMed and PsyINFO were searched using the terms “psychiatry inpatient suicide,” “coping inpatient suicide,” “acute inpatient suicide,” and “psychiatric ward suicide.” A total of 821 articles are cited. After a review of titles, abstracts, or text, the authors included 41 articles published between 1982 and 2007 documenting 5,396 patients successful in ending their lives. Studies are drawn from various countries and cultures in the United States, Europe, and Asia. Articles were chosen that evaluated suicides occurring while patients were hospitalized on an acute psychiatric unit or soon after discharge. Studies addressing suicide in the outpatient setting or in correctional settings were excluded as were studies of single cases and single diagnoses.
Epidemiology of Suicide in Hospitalized Patients
The inpatient suicide rate in the US, China, New Zealand, Australia, Austria, and the United Kingdom ranges from 100–400 per 100,000 inpatient psychiatric admissions.8-11 Three percent to 28% (median 23.5%) of inpatient suicides occur during the first week of hospitalization, while 17% to 71% (median 39.5%) occur within the first month (Table 1).3,6-9,11-25 Several studies discussed length of stay, a factor crucial for data interpretation. Sharma and colleagues21 identified the mean length of stay of patients who killed themselves at 185 days compared to 124.2 days for controls. Shah and Ganesvaran3 found a median stay of 44.5 days, while Erlangsen and colleagues14 noted a median length of stay of 28 days. Even with accounting for distribution of patient days, Erlangsen and colleagues14 described a significantly higher proportion of suicides occurring within 7 days of admission.
The majority of studies show that affective disorders1,5-9,15,22 or schizophrenia1,5,10 are most frequently associated with inpatient suicide (Table 1). Multiple studies also find schizophrenia and affective disorders to be the most common diagnoses of inpatient psychiatric patients (Table 2).3,6,8,11,16,22,23,26 Given that schizophrenia and affective disorders are the most common diagnoses, it would be expected that these diagnoses would be heavily represented in patients that commit suicide. However, in multiple studies the incidence of schizophrenia is higher in the suicide cohorts compared to controls.11,16,22,23 The prevalence rates of diagnoses vary as they reflect the heterogeneous sites of study. The studies cited in Table 1 include data from state, private, university, and public hospitals. Proportionally, more schizophrenic patients are usually found in state hospitals providing care for the chronically mentally ill,23,27,28 while those with affective disorders are more frequently hospitalized in facilities caring for acutely ill patients.10,23
Most suicides occur while patients are off the psychiatric unit.3,4,6,7,13,19,22,23,25,27 Studies show that 7% to 65% (median 36%) of patients were out of the hospital without permission at time of death and 19% to 81% (median 30%) were on approved leave when they killed themselves. Meehan and colleagues25 reported that the majority of all patients who committed suicide on or off unit were judged to be at no or low immediate risk at last contact with staff. This finding highlights the difficulty in assessing suicide risk in inpatient psychiatric patients.
Methods of suicide depend on whether the patient is on or off unit at time of death. Substances potentially employed for overdose are typically unavailable for an inpatient so this method is rarely used. Suicides on ward are usually accomplished by hanging,13,22 an accessible means. Off-ward suicides are often violent: hanging or jumping from a height or in front of a moving vehicle (Table 1).3,6,7,10,19,25,28
Inpatient Suicide Risk Factors
Multiple risk factors have been identified for risk of inpatient suicide. Patients who kill themselves might have previously indicated to others that they were considering suicide. Busch and colleagues15 note that 78% of patients denied suicidal ideation prior to the act, and Deisenhammer and colleagues10 found that 40.9% patients had not expressed any suicidal thoughts. Furthermore, Fawcett and colleagues29 identified suicidal ideation more often in patients who did not kill themselves compared to those who actually took their own lives. However, Powell and colleagues9 identified suicidal ideation and attempts at self harm as the most predictive risk factor in their study of 112 inpatient suicides.
Patients may indicate that their suicidal symptoms abated yet progress to self harm. Dong and colleagues8 identified 40.9% patients, Goh and colleagues18 identified 40%, Morgan and Priest24 cited 51%, and Deisenhammer and colleagues10 found that 22.7% of patients had improved psychiatric symptoms prior to suicide. Deisenhammer and colleagues10 also noted that 44% of patients had discharge plans in progress at time of death, indicating hopefulness for life after hospitalization.
Suicide risk for inpatients is unique. Numerous factors associated with suicide in the general population such as substance abuse as well as being single, unemployed, or living alone are not consistently associated with inpatient suicides.9 However, other factors linked with suicide in the general population appear to be associated with inpatient suicide. Chronic mental illness including mood and psychotic disorders are most consistently predictive of inpatient suicide.1,3,4,6,8,11,13,15,16,18,22,23,27 Previous episodes of self-abusive behaviors and history of suicide attempts, especially during the index admission, are also significant predictors.3,4,6,11,13,17,18,22 Several studies11,18,23,26 identified increased length of hospital stay, multiple previous admissions,22,24 longer duration of illness,20,22 and male gender.6-8,19 Meehan and colleagues25 note that the majority of patients are hospitalized by their own choice with involuntary admission identified as an inconclusive risk factor.8,22,27 Identified risk factors including those less commonly noted are listed in Table 3.3,6-12,13,14,16-25,30-32
Predicting Inpatient Suicides
Several researchers have attempted to predict inpatient suicide using identified risk factors. Powell and colleagues9 identified five predictive risk factors. However, upon review only two of the 97 patients in their data set that committed suicide had a predicted risk of suicide >5%. The authors9 concluded that although several factors identified were strongly associated with suicide, their clinical utility is limited by low sensitivity and specificity, a product of the minimal rate of suicide even in this high-risk group. Spiessl and colleagues23 found that although they also could identify five significant predictors, their model failed to identify any of the patients who committed suicide. Other researchers have tried to develop predictive schema but have been unable to generate models with sufficiently high sensitivity and specificity.33 A study by Hunt and colleagues6 found that a multivariate model included three independent predictors of suicide, including being male, having a diagnosis of affective disorder, and previous deliberate self harm. Thirteen percent of suicide cases had all three compared to 5% of controls (P=.003).
Impact of Medications
The relationship of pharmacotherapy to inpatient suicide was not a focus of most articles reviewed. Of 41 articles in the survey, only 13 identified either drug choice or compliance. A German study16 compared medication treatment of 61 suicide victims to an age-, gender-, and diagnosis-matched control group taken from 27,078 admissions over a 20-year period. Half the patients who killed themselves had schizophrenia and four of the 27 patients in the suicide group had been off their antipsychotics for ≥10 days. Lorazepam had been more often reduced or withdrawn than in the controls in the 10 days preceding suicide. The highest suicide risk was in patients with schizoaffective disorder who had a recent change in antidepressant or dose. The authors concluded that if an antidepressant was to be changed, accompanying benzodiazepines should be more liberally prescribed. They advised the use of mood stabilizers, especially lithium, which has been shown in a controlled study to prevent suicide in patients with a history of previous suicide attempts.34 The author of another German study35 noted that only clozapine proved effective in bringing about stabilization in a patient who twice tried to kill himself by jumping from a tall building during hospitalization. This is consistent with evidence of clozapine’s efficacy in reducing suicidal risk in schizophrenic patients.36
Dong and colleagues8 reviewed 93 hospitalized patients who had committed suicide and found that the number of patients prescribed antidepressants was similar to that of controls. All had expressed depressive symptoms within 2 weeks of suicide whether their diagnosis was major depressive disorder, substance-induced depression, bipolar depression, or depression associated with a psychotic disorder. Twenty-two percent of patients were on antidepressants but all were taking less than the maximum dose. Sixty-six percent of patients were taking oral antipsychotics and 37% were on a depot form of these drugs. Fourteen percent experienced extrapyramidal symptoms or akathisia. Dong and colleagues8 surmised that a relationship between suicidal impulses and akathesia can only be hypothetical.
Medication noncompliance is thought to contribute to relapse, a factor considered to increase suicide risk in the short term.30 Cassells and colleagues4 note that 20% of inpatients with schizophrenia and 40% to 70% of outpatients with schizophrenia are estimated to be medication noncompliant.
Anxiety disorders are an independent risk factor for suicide.37 In a review of 76 patients who had committed suicide during hospitalization, Busch and colleagues15 note use or non-use of anxiolytics. These medications were usually offered after staff assessment rather than by patient request. In some instances, helpful anxiolytics were discontinued. In general, doses were low and often inadequate to control severe anxiety.
Sharma and colleagues21 speculated that mood instability could be associated with increased risk of suicide. They proposed that treatment with antidepressants and even electroconvulsive therapy can induce both mixed states and rapid cycling, thereby elevating the possibility of suicide.
Suicide in Older Individuals
Few studies have examined suicide events in elderly inpatients. Erlangsen and colleagues14 reviewed 37,172 people ≥60 years of age admitted to a psychiatric inpatient unit in Denmark between 1990 and 2000. One-hundred ten patients died by suicide during hospitalization. Men comprised 43% and women 57%. The authors concluded that patients with dementia had a lower suicide risk, but patients who committed suicide were more likely to have a greater number of comorbid diagnoses of physical illness and accompanying affective disorders.
Shah and Ganesvaran38 found that only 8% of all inpatient suicides in a large psychiatric hospital in Melbourne, Australia over a 21-year period were by patients >60 years of age. When compared to younger inpatient suicides, elderly patients were more likely to be depressed, less likely to have schizophrenia, have more children, and have a longer interval between the age of onset of the illness and the index admission. A high degree of vigilance in those elderly patients with depression, alcohol abuse, and expressed suicidal ideation is advised.
In-Hospital Risk Monitoring
Numerous studies reviewed the association of patient monitoring with inpatient suicide. This includes constant staff observation or checks by staff at short intervals. Busch and colleagues15 noted nine of 45 patients who killed themselves had been monitored every 30 minutes or seen by staff within 30 minutes of suicide, nine were checked every 15 minutes or observed at least 15 minutes before the event, and four were continuously observed. Powell and colleagues9 found that 25 patients (26%) who killed themselves were on formal nursing observation, and two were continuously observed at time of death. Meehan and colleagues25 found that 57 of 754 (8%) patients ended their lives after absconding while on medium- or high-level observation.
Suicide Risk Post-Hospitalization
A group of patients did not attempt suicide during hospitalization but chose to end their lives almost immediately or soon after discharge. Meehan and colleagues25 evaluated risk of suicide during the 3 months following discharge. Of 1,100 patients committing suicide within this period, 337 (32%) occurred within the first 2 weeks and 32 (3%) died on the first day following discharge. The most common methods were hanging and overdose. Furthermore, 397 deaths (40%) occurred before the patients’ first post-discharge mental health follow-up appointment in the community. This group was often homeless and had severe mental illness, multiple previous admissions, and a history of previous self harm. Erlangsen and colleagues14 evaluated 77 patients who committed suicide after discharge and found that 34% died within the first week.
Deisenhammer and colleagues20 evaluated suicides between 1996 and 2002 in Tyrol, Austria. Of 665 suicides 109 (16.4%) had been hospitalized in the year prior to death. Of these patients, 12.8% killed themselves on the day of discharge, 28% ended their lives within 7 days of discharge, and 48% committed suicide within 1 month of discharge.
Impact on Staff and Patients
Little research exists on how mental health professionals cope with everyday stress on an inpatient ward. Norwegian authors Hummelvoll and Severinsson39 described interviews with 16 mental health professionals who emphasized the pressures experienced in routine, everyday work life. They cited an unpredictable and demanding work climate, diffuse responsibilities, occasional lack of clinical supervision, and inadequate or dangerous surroundings as contributing to anxiety and eventual burnout.
In an already tense inpatient environment, patient suicide engendered increased stress. Spitzer and Burke40 enumerated multiple symptoms experienced by staff following a critical incident, including cognitive impairments with inability to make decisions as well as anger, irritability, paranoia, inattention, guilt, and depression. Staff also reported physical problems such as fatigue and headaches following the death of a patient in their care. Joyce and Wallbridge41 considered the effects of several suicides on nine nursing staff members on an adult acute care psychiatric unit and reflected on which supportive activities related to the incidents were helpful. Most staff felt shocked, stressed, and sad. Many identified with the patient or the patient’s family. One employee interviewed said, “I was good at masking my feelings at work, but when I left, I’d just sit alone in my car and cry.” Workers were often angry, vigilant, tense, and critical of colleagues’ management of the incident. Some felt ostracized and blamed. Those who adhered to spiritual beliefs appeared to cope better. Some could, after time, say how dealing with death affirmed their regard for life.
Approaches to staff reactions to patient suicide varied. Joyce and Wallbridge41 noted that some found post-event debriefing helpful while others felt overwhelmed by a meeting and wanted to be left alone. Many needed to have their guilt assuaged. Cotton and colleagues42 noted that informal peer contact was the most valuable intervention for staff. They emphasized acceptance of the suicide as the patient’s personal choice. Blythe and Pearlmutter43 argued that patient safety while hospitalized is important and it is unreasonable to assume that staff is ultimately responsible for the patient’s life.
Researchers concluded that before any intervention, good background information pertaining to the incident must be obtained. Team members’ psychological resilience, experience with similar episodes, and worker cohesiveness must be assessed. They stressed that participation in debriefing should be voluntary and follow-up with mental health services should be offered. Midence and colleagues44 recommended providing support from senior nurses and psychiatrists and suggested scheduling follow-up staff meetings to review assessment and prevention policies.
Patients on the ward at the time of the incident need special attention. Those with a history of suicidal behavior may be principally affected. Bowers and colleagues45 stressed how surviving patients are often ignored and not provided with sufficient support. Kayton and Freed46 recommended patient-staff meetings. Olin47 suggested offering memorial service and scrutinizing patient off-ward privileges. Kaye and Soreff47 underscored the role of psychiatrist as leader with numerous responsibilities in the aftermath of suicide including notifying family; meeting with family, staff and patients to open discussion and vent feelings; documenting events; and possibly attending the funeral.
Suicides on the inpatient unit are infrequent but tragic and generally unpredictable events. Although studies have identified risk factors for this occurrence, the ability to employ them to effectively predict which individuals will end their lives as inpatients has proven difficult. Interpretation of the data is challenging given inconsistent design methods and heterogeneity in the populations studied. However, some findings including diagnoses associated with inpatient suicide, method chosen to end one’s life, site of death, high risk periods, and incidence are consistent and, therefore, can improve management of inpatient psychiatric patients.
Although the ability to predict which individuals will commit suicide is poor, there are possible precautions to reduce risk. Medications should be offered in adequate doses. For patients considered at high risk, direct, individual supervision while hospitalized is advised. Suicides in a locked ward are fewer compared to those taking place while patients are off unit. A significant number of patients were off unit at time of death because they had eloped. Suicides might have been avoided by preventing patients leaving the unit without permission. Absconded patients must be actively sought because of their high risk for self harm.23 Given the first week of hospitalization is a time of increased vulnerability, careful assessment of patients given permission to go off ward may also reduce deaths.
Changes in the immediate hospital environment can also help prevent inpatient suicides. Access to potentially lethal means should be reduced. Meehan and colleagues25 found that of 236 deaths in the inpatient unit, 73% were by hanging. Nineteen patients hung themselves with a belt. Patients at risk should be denied access to belts, bathrobe cords, and shoe laces. Safety features such as shower heads that give way when pressure is applied and eliminating wall hooks reduce access to means. Meehan and colleagues25 also reported that in 184 cases, staff were unable to keep patients in view secondary to poor ward design.
Patients are particularly vulnerable in the week following discharge. With the current trend for short hospital stays, clinicians may feel pressure to release patients before they are stable enough to cope with the outside environment. Detailed disposition planning with close follow up post-discharge may help ease the transition to the stress outside of the hospital and reduce risk of suicide.
The potential for suicide may be present from the initiation of hospitalization, but our ability to determine individuals at risk is, at best, poor. Factors linked with suicide in the general population appear to differ from those associated with inpatient suicide. However, measures can be taken to try to reduce risk in the inpatient setting and during the time immediately after discharge. The hope is that with further study, we will find improved methods of identifying those at risk and preventing a fatal outcome. PP
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