Prospective study of risk factors for increased suicide ideation and behavior following recent discharge

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General Hospital Psychiatry 34 (2012) 88 – 97

Emergency Psychiatry in the General Hospital The emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater acuity and comorbidity than previously known. This Special Section will address those overlapping aspects of psychiatric, medicine, neurology, psychopharmacology, and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.

Prospective study of risk factors for increased suicide ideation and behavior following recent discharge☆ Paul Links, M.D. a, b, c,⁎, Rosane Nisenbaum, Ph.D. c, d, e , Munazzah Ambreen, M.B.B.S., M.Sc. a , Ken Balderson, M.D. f , Yvonne Bergmans, M.S.W. a , Rahel Eynan, M.A., Ph.D. a , Henry Harder, Ph.D. g , John Cutcliffe, Ph.D. h, 1 a

Suicide Studies Research Unit at St. Michael's Hospital, Toronto, Ontario, Canada b Department of Psychiatry, Faculty of Medicine, University of Toronto, Canada c Centre for Research in Inner City Health in The Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada d Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada e Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Canada f Inpatient Mental Health Unit at St. Michael's Hospital and Department of Psychiatry, University of Toronto, Canada g Health Sciences Programs at the University of Northern British Columbia, Prince George, BC, Canada h Acadia Professional Chair Psychiatric and Mental Health Nursing at Psychiatric and Mental Health Nursing at the University of Maine, USA Received 18 February 2011; accepted 12 August 2011

Abstract Objective: The purpose of this study is to prospectively examine the association between predictors from the three thematic areas — suicidality, personal risk factors and patient care factors — and the occurrence of postdischarge suicide ideation and behavior in recently discharged patients. Methods: The design is a prospective cohort study of all patients admitted to an inner city inpatient psychiatric service with a lifetime history of suicidal behavior and current suicidal ideation. Predictors of suicide ideation at 1, 3 and 6 months following discharge and suicide behavior over the 6 months of follow-up were examined. Results: The incidence of death by suicide during the study period was 3.3% [95% confidence interval (CI)=0.9%–8.3%], and 39.4% (95% CI=30.0%–49.5%) of the surviving participants reported self-injury or suicide attempts within 6 months of hospital discharge. Risk factors such as recent suicide attempts, levels of depression, hopelessness and impulsivity were predictive of increased suicide ideation or behavior after discharge from the inpatient service. Conclusions: The high risk of suicide ideation, suicide attempts and suicide demonstrated in these recently discharged patients supports the need to develop selective prevention strategies. © 2012 Elsevier Inc. All rights reserved. Keywords: Suicide behavior; Suicide ideation; Recent discharge; Risk factors; Psychiatry

☆ Declaration of Interest: Paul S. Links has received an unrestricted educational grant from Eli Lilly Canada Inc. Rosane Nisenbaum gratefully acknowledges the support of the Ontario Ministry of Health and Long-Term Care. The views expressed in this publication are the views of the authors and do not necessarily reflect the views of the Ontario Ministry of Health and Long-Term Care. ⁎ Corresponding author. Suicide Studies at St. Michael's Hospital, Toronto, Ontario, Canada. Tel.: +1 416 864 6099; fax: +1 416 864 5996. E-mail address: [email protected] (P. Links). 1 He also holds Adjunct Professor of Nursing positions at the University of Ulster, UK and the University of Malta.

0163-8343/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2011.08.016

P. Links et al. / General Hospital Psychiatry 34 (2012) 88–97

1. Introduction Suicide is a prevalent cause of death around the world [1], and patients with psychiatric illnesses have a much higher rate of suicide than the general population [2,3]. Those whose illness necessitates psychiatric hospitalization are at an increased risk of suicide [4]. Studies show that suicides cluster in the postdischarge period [5] and that 57% to 100% of psychiatric patients who die by suicide have been in contact with inpatient psychiatric services within 1 year of their death [6]. The increased risk of suicide in the postdischarge period has been observed in different countries, populations and time periods [2,7–9]. A study done in Hong Kong has shown that standardized mortality ratios (SMRs) in the first month after discharge were 4.6 times higher in males and 4 times higher in females in comparison to the 29- to 365-day period [9]. Standardized mortality ratios for the same postdischarge periods using a population-based study of the Oxford health region in the UK reported that, in the first 28 days following discharge, SMRs were 7.1 times higher among male patients and 3.0 times higher among female patients than the 29- to 365-day period [7]. With regards to suicide in the first week following discharge, Qin and Nordentoft [10] calculated the population attributable risk based on their findings from the Danish national longitudinal registers and estimated that prevention efforts during the first week after discharge might impact up to 6% of all suicides. Although it is clear that the rate of suicide is higher in the weeks and months following discharge from a psychiatric inpatient service compared to the general population, predicting who is at a higher risk during this time is more difficult. Therefore, it is important to determine the risk factors for suicide after discharge from hospital because they could be useful in identifying targets for selective prevention strategies. From previous retrospective studies, Troister et al. [5] recently completed a review identifying predictors of suicide that occur within 1 year of discharge from a psychiatric inpatient service. From their review, the authors identified that the predictors fell into three thematically related categories: (1) factors related to suicidality, (2) personal risk factors such as sociodemographic and psychopathological features and (3) patient care factors. Related to suicidality, discharged patients who died by suicide versus those who did not were more likely to have attempted suicide in the past, have a higher mean number of previous suicide attempts [6], have more than one suicide attempt in the past [11,12] or have a history of deliberate self-harm [2,6]. Studies comparing patients who died and did not die by suicide within 1 year of discharge found suicide ideation or attempts before admission to be a risk factor for suicide [2,6,11,13]. Self-harm or suicide attempts during an admission were also found to be a significant risk factor for suicide [2,13,14]. Personal risk factors including being unemployed [2,6], living alone or not with either parent, having an unsatisfac-

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tory relationship with parents [2,12,15] and having low social support [2,12,15], as well as affective disorders, depressive symptoms [6,12,14–16] and the diagnosis of schizophrenia [13,16], were found to be significantly associated with increased risk of suicide postdischarge. In addition, patients who died by suicide after discharge had experienced significantly more losses in the previous year than controls [13]. Regarding patient care factors, the majority of studies found that shorter hospital admissions have been associated with increased risk for suicide after discharge from hospital [16–18]. In particular, length of inpatient stay of 1 to 7 days or 7 to 14 days compared to longer stays has been associated with higher risk for subsequent suicide attempts [16]. A more recent study, however, has found opposite results [19]. Poor compliance with treatment including medication compliance in the postdischarge period was also reported to be a important risk factor for postdischarge suicide [6,20]. Finally, continuity in care versus discontinuity in care in the transition from pre- to postdischarge seemed to act as a protective factor against attempted suicide [2]. Having fewer follow-up appointments in the postdischarge period has also been associated with an increased risk of suicide [16]. The purpose of the current research is to simultaneously examine the association between predictors from the three thematic areas discussed above and the occurrence of postdischarge suicide ideation and behavior in high-risk cohorts of recently discharged patients. To this end, we identified high-risk inpatients based on a history of lifetime suicidal behavior and current suicide ideation and conducted a prospective study of two well-defined cohorts of these inpatients: those who were at risk for lack of continuity of care at time of hospital discharge and those who were not at risk. The participants were followed up prospectively for evidence of suicide ideation and behavior at 1, 3 and 6 months after hospital discharge. 2. Methods 2.1. Study groups and recruitment This study was carried out in a large urban general hospital with an active inpatient psychiatric service between May 2007 and December 2009. A concurrent quantitative– qualitative methods design was utilized, but here we only report the quantitative component. The qualitative findings will be published separately [21,22]. The initial assessment of consecutive patients admitted to the inpatient psychiatric service and a short-stay crisis stabilization unit was screened for high-risk patients. Highrisk was defined as having a lifetime history of suicidal behavior accompanied by some level of intent to die and current suicidal ideation as documented in the admission assessment. The attending physician asked these patients for permission to be approached by the study coordinator. Once permission was given, the study coordinator informed

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patients of the study and obtained their consent to participate in the investigation. After providing signed informed consent, patients participated in the baseline assessment during their hospital admission. The study received research ethics approval from the hospital Research Ethics Board. 2.2. Not supported: risk of lack of continuity of care We defined inpatients who were at risk for a lack of continuity of care on discharge because they had no customary mental health/health care provider available on admission to hospital as being “Not Supported” and at higher risk of suicide. The “Supported” cohort was defined by individuals who had a customary mental health/health care provider available on admission and were not at risk for a lack of continuity of care on discharge. 2.3. Baseline measures While in hospital, the participants were assessed for baseline suicidal ideation measured with the clinician-administered version of the Scale for Suicide Ideation (SSI), [23] a 21-item, interviewer-administered rating scale that measures the current intensity of the participants' specific attitudes, behaviors and plans to die by suicide on the day of the interview and during the preceding week. This scale has demonstrated internal consistency, interrater reliability and concurrent validity [23] and adequate predictive validity significantly predicting eventual suicide [24]. To assess major current and lifetime psychiatric disorders (Axis I) and personality disorder diagnoses (Axis II), the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (SCID I and II) [25] was used. The SCID I is a semistructured interview for making the major DSM-IV Axis I diagnoses. The output of the SCID is a record of the presence or absence of each of the disorders being considered, for current episode (past month) and for lifetime occurrence. The SCID II is a semistructured diagnostic interview for assessing the 12 DSM IV Axis II personality disorders. It closely follows the language of the DSM-IV Axis II Personality Disorders criteria. The interviews were administered by a clinician with psychiatric training and experience. Participants were also assessed during their index hospital admission for a history of suicidal behavior; severity of depression, hopelessness and impulsivity; deficits in emotional regulation, problem-solving skills, supports, life stress, symptom intensity and health outcomes using the following standard questionnaires. To assess the history of suicidal behavior, the Parasuicide History Interview (PHI) [26] was administered. The PHI is a widely used structured interviewbased measure used to collect details regarding time, circumstances, motivations, lethality and treatment of each parasuicide event that the subject can recollect in the year prior to their admission. The PHI is designed to assess the frequency, medical severity, lethality and precipitants associated with parasuicidal episodes.

The self-administered questionnaires included the Beck Depression Inventory (BDI-II) [27,28], which is a 21-question multiple-choice self-report inventory, one of the most widely used instruments for measuring the severity of depression. The BDI-II has demonstrated internal consistency (Cronbach's alpha for psychiatric populations ranges from 0.76 to 0.95), convergent validity with hopelessness and suicidal ideation, and a strong positive association with an earlier version of the measure [27,28]. To assess hopelessness, Beck Hopelessness Scale (BHS) [29], a 20-item self-report inventory, was used. This questionnaire was designed to measure three major aspects of hopelessness: feelings about the future, loss of motivation and expectations [29]. The BHS has demonstrated internal consistency (Cronbach's alpha ranges from 0.82 to 0.93) and convergence with clinician ratings of hopelessness [correlation coefficients ranges from (r) 0.62 for inpatients to 0.74 for medical patients] and with measures of depression and suicide intent (r=0.68) [29,30]. Impulsivity was recorded using Barratt's Impulsivity Scale (BIS-11) [31], a 30-item self-report questionnaire that is a widely used measure of impulsive traits. The BIS-11 has demonstrated internal consistency (Cronbach's alpha ranging from 0.89 to 0.92 for all the three subscales), clinical utility and trait specificity [31]. The Toronto Alexithymia Scale (TAS-20) [32] is a 20item instrument that is one of the most commonly used measures of alexithymia. The TAS-20 has been used in a variety of populations, including psychiatric outpatients, and previous evidence supports the convergent, discriminate and concurrent validity of the TAS-20 [33–35]. Problem-solving skills were assessed using ProblemSolving Inventory (PSI) [36,37], a widely used self-report measure of applied problem solving. Based on previous research, the PSI has demonstrated adequate reliability and validity [37,38]. The People in Your Life [39] inventory assesses psychiatric patients' perceptions of the quality and quantity of supportive relationships. The scale has shown good subscale alpha coefficients, test–retest reliability and face and construct validity [39]. Subjective Response to Events Scale (SRES) [40] was used to assess patients' perception of the events 1 month preceding their admission to the hospital. The SRES has demonstrated acceptable psychometric properties [40]. 2.4. Follow-up measures The SSI was administered at 1, 3 and 6 months after hospital discharge. At the sixth-month follow-up appointment, participants were asked to report on any self-injury events without intent to die or suicide attempts with intent to die during the 6 months after their hospital discharge using the clinician-administered Lifetime Parasuicide Count [41]. When possible, follow-up appointments were scheduled with participants in hospital prior to discharge. However, in

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Table 1 (continued) Table 1 Sample characteristics Suicidal history and Ideation at admission Reason for admission (n, %) First suicide attempt Current suicide ideation and previous suicide attempt Current and previous suicide attempt Number of past suicide attempts before admission (n=93) Median (interquartile range) Scale of suicide ideation, mean (S.D.) Sociodemographics Age (n=119), mean (S.D.) Gender (n, %) Male Female Race/ethnicity Caucasian Black Asian Other Marital status (n, %) Single Married/common-law Divorced/separated/widowed Education (n, %) Less than high school High school College/university/graduate school Current place of residence (n, %) Shelter Living with parents/family Rent Own Source of income in the past year (n, %) Disability pension Other Current employment status (n, %) Full time Part time Self-employed Student Disabled Unemployed Psychopathological factors, mean (S.D.) Depression (n=105) BDI-II, mean (S.D.) Hopelessness (n=114) BHS, mean (S.D.) Impulsivity (n=107) BIS, mean (S.D.) Alexithymia (n=114) TAS-20, mean (S.D.) PSI (n=110) Problem-solving confidence Approach avoidance style Personal control Current psychiatric diagnoses (n, %) Substance use Alcohol use Major depression disorder Affective disorder (bipolar or major depression) Schizophrenic disorder (schizophrenia or schizoaffective) Borderline personality disorder Number of Axis II disorders a (n=113) Median (interquartile range)

27 (22.5) 22 (18.3) 71 (59.2) 2 (2) 23.6 (3.8) 37.5 (11.1) 63 (52.5) 57 (47.5) 87 (72.5%) 7 (5.8%) 6 (5.0%) 20 (16.7%) 84 (70.6) 14 (11.8) 21 (17.6)

Care factors Mental health/health care provider available on admission (n, Not supported Supported Length of hospital admission (days) (n, %) 1–3 4–11 N11 Median (interquartile range)

%) 24 (20.0) 96 (80.0) 61 (50.8) 13 (10.8) 46 (38.4) 3 (14)

a

Number of Axis II diagnoses includes avoidant or dependent or obsessive–compulsive personality disorder (OCPD) or passive–aggressive or depressive or paranoid or schizotypal or schizoid or histrionic or narcissistic or borderline or antisocial.

cases where patients were discharged without appointments, the study coordinator called participants and invited them to schedule a follow-up appointment over the phone. 2.5. Outcomes

24 (20.3) 8 (6.8) 73 (61.9) 13 (11.0)

For suicidal ideation, we considered two outcomes: (1) change in SSI scores from baseline to 1 month postdischarge and (2) SSI scores at 1, 3 and 6 months postdischarge dichotomized as ≥3 (indicating that the patient is positive for suicide ideation) and b3 (negative for suicide ideation) [24]. We used these SSI categories due to the high proportion of zero scores at follow-up. For suicide behavior within 6 months of hospital discharge, we used the composite of the indicator of suicide attempts with intent or ambivalence to die or death by suicide.

57 (47.9) 62 (52.1)

2.6. Statistical analyses

32 (26.9) 22 (18.5) 65 (54.6)

21 (17.8) 12 (10.2) 3 (2.5) 4 (3.4) 53 (44.9) 25 (21.2)

39.1 (11.6) 13.0 (5.0) 75.9 (9.5) 61.5 (9.6) 39.9 (9.8) 57.8 (9.5) 22.2 (4.1) 47 48 78 99 12 36

(42.7) (43.6) (70.9) (90.0) (10.9) (31.9)

1 (1)

Descriptive statistics (mean, standard deviation, quartiles) were calculated to characterize the participants with respect to suicidal history (i.e., hospital admission due to suicide attempt or suicide ideation, number of past suicide attempts before hospital admission) and the predictive variables from the three thematic areas: sociodemographics at admission (age, gender, marital status, current place of residence, employment status, receiving disability), psychopathologic risk factors at/during admission (BDI-II, BHS, BIS, TAS-20, PSI), presence of affective disorders, schizoaffective disorders, substance use disorders, number of Axis II disorders, borderline personality disorder, indicator of “Not Supported” at admission and length of hospital admission (patient care variables). Predictors associated with change in SSI scores from baseline to 1 month were identified using linear regression models. We fitted logistic generalized estimating equations (GEE) models with exchangeable correlation structure [42] to determine predictors of risk of being positive for suicide ideation postdischarge while accounting for the correlations between repeated SSI measures at 1, 3 and 6 months. Suicide behavior at 6 months after hospital discharge was analyzed using logistic regression analysis. Univariate models assessed associations between factors in each of three thematic areas and suicide ideation and behavior.

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A sequence of multivariate models was fit, starting by including all factors with univariate P valuesb.20 [43,44] and the indicator of lack of a customary mental health/health care provider upon hospital admission (Not Supported). Next, factors were dropped from the model if P values were N.20 and they had missing data. A new model was fit with the remaining variables, and the process was repeated. The final multivariate model included statistically significant (P valueb.05) and clinically relevant variables, adjusting for exposure status. Suicide behavior at 6 months after hospital discharge was analyzed using logistic regression analysis applying the purposeful selection of variables algorithm described in Bursac et al. [45]. This method first evaluates univariate associations and select variables with preselected significance level (P=.20) as candidates for the multivariate analysis. Variables are kept in the multivariate model if significant (Pb.10) or if a confounder (percent change in any remaining parameter estimate greater than 20% as compared to the full model). Next, any variable not selected for the original multivariate model is added back one at a time, with significant covariates and confounders retained earlier (P=.10). The process is repeated and ends when no

additional variables enter the model, and adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated. All analyses were performed using SAS v9.2 (SAS Institute Inc., Cary, NC, USA). 3. Results 3.1. Sample description A total of 152 inpatients were eligible and 120 (78.9%), consented to participate in the study. By the end of the study, 10 (8.3%) participants had withdrawn, and 8 (6.7%) were lost to follow-up. Table 1 shows the description of the baseline sample. There were similar numbers of male (52.5%) and female (47.5%) participants, and the mean age was 37.5 years (S.D.=11.1). Most participants were admitted because of a current suicide attempt, but 22 (18.3%) were admitted because of suicide ideation. Only 27 (22.5%) participants were first-time suicide attempters, i.e., had no suicide attempts in the past, while 93 (78.5%) had a median number of two previous attempts (interquartile range=2) over their

Table 2 Predictors of change in suicide ideation from baseline to 1 month in univariate and multivariate linear regression analyses

Intercept Suicidality factors First suicide attempt Number of past suicide attempts before current admission, N1 vs. ≤1 Reason for admission, suicide attempt vs. suicide ideation Sociodemographic factors Age, 1-year increase Female Single Living in a shelter Disability pension in the past year Currently unemployed Psychopathological factors Depression, BDI-II Hopelessness, BHS Impulsivity, BIS Alexithymia, TAS-20 PSI, problem-solving confidence PSI, approach avoidance style PSI, personal control Substance use disorder Affective disorders (bipolar or major depression) Schizophrenic disorders (schizophrenia or schizoaffective) Borderline personality disorder Number of Axis-II disorders a, N1 vs. ≤1 Patient care factors Mental health/health care provider not available on admission, “Not Supported” Length of admission in hospital (days) 1–3 vs. N11 4–11 vs. N 11

Univariate linear regression

Multivariate linear regression b

Estimate (S.E.)

Estimate (S.E.)

P value

−23.69 (2.38)

b.0001

5.41 (1.67)

.0017

2.73 (1.59)

.0894

P value

−2.01 (2.19) 6.31 (1.71) 3.16 (2.26)

.3617 .0004 .1660

0.02 (0.08) 3.27 (1.77) −0.33 (1.98) −1.64 (2.17) 0.02 (1.79) −2.81 (2.15)

.8232 .0670 .8667 .4534 .9911 .1958

0.11 (0.08) 0.46 (0.17) 0.17 (0.09) 0.12 (0.10) 0.11 (0.09) 0.08 (0.09) 0.04 (0.22) 3.02 (1.79) 0.09 (3.05) 2.48 (3.04) 1.98 (1.88) −4.34 (2.15)

.1604 .0093 .0722 .2267 .2430 .4227 .8356 .0948 .9754 .4156 .2964 .0464

0.36 (0.16)

.0256

−4.97 (1.93)

.0115

2.76 (2.15)

.2025

2.78 (1.93)

.1545

−3.25 (1.92) −1.52 (2.96)

.0938 .6073

a Number of Axis II diagnoses includes avoidant or dependent or OCPD or passive–aggressive or depressive or paranoid or schizotypal or schizoid or histrionic or narcissistic or borderline or antisocial. b R 2=0.26.

P. Links et al. / General Hospital Psychiatry 34 (2012) 88–97

lifetime. Twenty-four (20%) participants did not have any form of outpatient mental health care in the community and therefore were at risk (Not Supported) for lack of continuity of care upon discharge. Ninety-six (80%) were Supported. Affective disorders were by far the most common current psychiatric diagnoses experienced by these participants with a history of suicidal behavior, and a current diagnosis of major depression or bipolar disorder according to DSM-IV criteria was present in 99 (90%) of the participants. Table 1 lists the other common current psychiatric diagnoses in these participants. Borderline personality disorder was diagnosed in 31.9% of the participants. The mean BDI score was 39.1 (S.D.=11.6). The median length of hospital admission was 3 days (interquartile range=14), and 38.4% remained hospitalized for 11 days or more. 3.2. Suicide ideation and behavior At baseline (n=119), SSI scores ranged from 10 to 31, with a mean of 23.6 and standard deviation of 3.8. Mean (S.D.) scores post discharge were 7.9 (9.0), 6.6 (7.8) and 5.7 (7.8) at 1 month (n=100), 3 months (n=96) and 6 months (n=98), respectively. Of note, a high proportion of

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participants reported no suicide ideation (SSI=0): 40.0%, 44.8% and 48.0% at 1, 3 and 6 months, respectively. The incidence of death by suicide during the study period was 3.3% (95% CI=0.9%–8.3%): one participant died (0.8% or 1 in 120) while hospitalized, and three participants (2.5% or 3 in 120) died within 1 month of hospital discharge. Of the participants who survived (n=104), 41 (39.4% 95% CI=30.0%–49.5%) reported self-injury or suicide attempts within 6 months of hospital discharge (32 had had intent to die, 2 were ambivalent, and 7 had no intent to die). 3.3. Change in SSI scores from baseline to 1 month Because of attrition, 100 participants had both baseline and 1-month SSI measurements. Overall, SSI scores significantly decreased from baseline to 1 month with a mean change of −15.7 (S.D.=8.9, range=−31 to 7, Pb.0001). From univariate analysis, the following variables were selected for the multivariate linear regression model (Pb.20): more than one past suicide attempt, hospital admission for a current suicide attempt, being female, being currently unemployed, BDI, BHS, BIS, substance use

Table 3 Predictors of positive suicide ideation (SSI scores≥3) at 1, 3 and 6 months in univariate and multivariate GEE models Univariate GEE model

Month of follow-up, for every month postdischarge Suicidality factors First suicide attempt Number of past suicide attempts before current admission, N1 vs. ≤1 Reason for admission, suicide attempt vs. suicide ideation Sociodemographic factors Age, 1-year increase Female Single Living in a shelter Disability pension in the past year Currently unemployed Psychopathological factors Depression, BDI-II Hopelessness, BHS Impulsivity, BIS Alexithymia, TAS-20 PSI, problem-solving confidence PSI, approach avoidance style PSI, personal control Substance use disorder Affective disorders (bipolar or major depression) Schizophrenic disorders (schizophrenia or schizoaffective) Borderline personality disorder Number of Axis II disorders a, N1 vs. ≤1 Patient care factors Mental health/health care provider not available on admission, “Not Supported” Length of admission in hospital (days) 1–3 vs. N11 4-11 vs. N 11

Multivariate GEE model

OR (95% CI)

P value

OR (95% CI)

P value

0.94 (0.86–1.02)

.1487

0.93 (0.83–1.03)

.1592

0.82 (0.41–1.66) 2.11 (1.09–4.05) 3.25 (1.37–7.72)

.5897 .0259 .0076

1.80 (0.94–3.44) 3.60 (1.27–10.76)

.0743 .0165

1.01 (0.98–1.04) 2.22 (1.17–4.21) 0.88 (0.45–1.72) 0.64 (0.30–1.35) 1.20 (0.64–2.25) 0.59 (0.29–1.21)

.4291 .0150 .7038 .2417 .5598 .1516

2.46 (1.20–5.05)

.0140

1.04 (1.05–1.07) 1.07 (1.01–1.14) 1.04 (1.00–1.08) 1.02 (0.99–1.05) 1.04 (1.01–1.08) 1.03 (1.00–1.07) 1.09 (1.01–1.18) 1.13 (0.60–2.16) 0.61 (0.23–1.61) 1.53 (0.48–4.88) 1.34 (0.69–2.63) 0.88 (0.40–1.89)

.0029 .0255 .0481 .1809 .0383 .0816 .0273 .7043 .3217 .4765 .3905 .7268

1.04 (1.01–1.07)

.0145

1.57 (0.71–3.50)

.2673

1.86 (0.76–5.52)

.1731

0.85 (0.42–1.71) 0.93 (0.36–2.41)

.6461 .8787

a Number of Axis II diagnoses includes avoidant or dependent or OCPD or passive–aggressive or depressive or paranoid or schizotypal or schizoid or histrionic or narcissistic or borderline or antisocial.

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disorder, more than one Axis II disorder and length of admission (Table 2). Negative regression coefficients indicate lower SSI scores at 1 month, while positive coefficients imply higher scores. In the final multivariate model (Table 2, N=98), history of more than one past suicide attempt and BHS scores were significantly associated with higher SSI scores at 1 month postdischarge (coefficient=5.41, S.E.=1.67, P=.0017 and coefficient=0.36, S.E.=0.16, P=.0256, respectively). However, more than one Axis II disorder was significantly associated with reduced SSI at 1 month after discharge (coefficient=−4.97, S.E.=1.93, P=.0115). Exposure and female gender were not statistically significant but were kept in the model because they were deemed clinically relevant for change in SSI scores. The R 2 for the final model was 0.26. 3.4. Positive (SSI≥3) and negative (SSIb3) for suicide ideation at 1, 3 and 6 months A total of 102 participants had at least one SSI measurement after hospital discharge. The prevalence of participants positive for suicide ideation was 59.0% (n=100), 54.2% (n=96) and 51.0% (n=98) at 1, 3 and 6 months,

respectively, but this trend was not statistically significant (P=.1487, Table 3). In multivariate analyses (Table 3, N=96, 279 measures), current suicide attempt compared with suicide ideation was significantly associated with positive suicide ideation (OR=3.60, 95% CI=1.21–10.75, P=.0216), even after adjusting for more than one suicide attempt before admission. Being female and higher BDI score at admission were also significantly associated with higher likelihood of positive suicide ideation at follow-up (OR=2.46, 95% CI=1.20–5.05, P=.0140 and OR=1.04, 95% CI=1.01–1.07, P=.0145, respectively). 3.5. Intentional harm or death by suicide within 6 months of hospital discharge For the logistic regression models, we considered participants who died by suicide or reported attempt with intent or ambivalence to die (N=37) and those who did not report any self-harm attempt (N=63) (Table 4). Participants who were admitted for suicide attempt compared with those admitted for suicide ideation had significantly higher odds of dying by suicide or attempting self-harm with intent/ ambivalence to die (OR=14.91, 95% CI=1.59–139.61).

Table 4 Predictors of the composite of self-harm with intent/ambivalence to die or death by suicide within 6 months of hospital discharge in univariate and multivariate logistic regression models

Suicidality factors First suicide attempt Number of past suicide attempts before current admission, N1 vs. ≤1 Reason for admission, suicide attempt vs. suicide ideation Sociodemographic factors Age, 1-year increase Female Single Living in a shelter Disability pension in the past year Currently unemployed Psychopathological factors Depression, BDI-II Hopelessness, BHS Impulsivity, BIS Alexithymia, TAS-20 PSI, problem-solving confidence PSI, approach avoidance style PSI, personal control Substance use disorder Affective disorders (bipolar or major depression) Schizophrenic disorders (schizophrenia or schizoaffective) Borderline personality disorder Number of Axis-II disorders a, N1 vs. ≤1 Patient care factors Mental health/health care provider not available on admission, “Not Supported” Length of admission in hospital (days) 1–3 vs. N11 4–11 vs. N 11

Univariate logistic regression

Multivariate logistic regression

OR (95% CI)

P value

OR (95% CI)

P value

0.90 (0.32–2.50) 1.48 (0.65–3.37) 5.96 (1.29–27.62)

.8360 .3533 .0226

14.91 (1.59–139.61)

.0179

0.98 (0.94–1.02) 1.64 (0.72–3.72) 1.26 (0.51–3.09) 2.23 (0.86–5.74) 1.47 (0.65–3.32) 0.65 (0.24–1.77)

.2264 .2358 .6194 .0981 .3540 .4017

3.61 (1.06–12.35)

.0405

1.02 (0.98–1.06) 1.07 (0.99–1.17) 1.05 (1.00–1.10) 0.99 (0.94–1.03) 1.00 (0.96–1.05) 1.03 (0.99–1.08) 1.00 (0.91–1.10) 1.79 (0.74–4.31) 0.29 (0.08–1.13) 1.66 (0.41–6.68) 1.08 (0.44–2.64) 1.73 (0.63–4.78)

.3335 .1072 .0401 .5519 .8977 .1417 .9756 .1968 .0742 .4760 .8735 .2874

1.06 (0.96–1.17) 1.09 (1.01–1.16) 0.93 (0.87–0.99)

.2294 .0198 .0237

1.24 (0.47–3.25)

.6675

1.11 (0.32–3.88)

.8730

1.11 (0.46–2.67) 0.89 (0.22–3.52)

.822 .8617

a Number of Axis II diagnoses includes avoidant or dependent or OCPD or passive–aggressive or depressive or paranoid or schizotypal or schizoid or histrionic or narcissistic or borderline or antisocial.

P. Links et al. / General Hospital Psychiatry 34 (2012) 88–97

Living in a shelter at time of admission and higher BIS scores were also positively associated with the odds of selfharm with intent/ambivalence to die (OR=3.61, 95% CI=1.06–12.35 and OR=1.09, 95% CI=1.01–1.16, respectively), but having higher TAS scores was negatively associated with self-harm with intent/ambivalence to die or suicide (OR=0.93, 95% CI=0.87–0.99). The BHS was not statistically significant but was a strong confounder for the other risk factors and therefore was kept in the model. Although Not Supported participants were 11% more likely to attempt/die by suicide than those Supported, this difference was not statistically significant (1.11, 95% CI=0.32–3.88). We kept this indicator in the model because we considered it an important preadmission clinical variable. We assessed all interactions between pairs of main effects, but none was statistically significant.

4. Discussion The current findings enhance our understanding of the risk of suicide following recent discharge from hospital in two ways. First, the prospective cohort design adds to the existing retrospective studies of the risk of suicide in recently discharged patients by confirming the remarkable risk for suicide in recently discharged patients [5]. In spite of receiving a high quality of psychiatric care, 3 of 120 participants went on to die by suicide within 1 month of discharge. In addition, 39.4% of the participants reported self-injury events or suicide attempts within 6 months of discharge from hospital, and the vast majority of events involved suicide attempts with intent/ambivalence to die. This high risk of suicide or suicide attempts in recently discharged patients supports the need to develop selective prevention strategies that will decrease the risk for suicide and suicidal behavior in this easily identified high-risk cohort [46]. Second, this prospective study adds to our knowledge of possible risk factors for positive suicide ideation, suicide attempts or suicide in recently discharged patients. Our study advances on previous research by prospectively studying high-risk cohorts of former inpatients and by accounting for risk factors from the three thematic areas identified in our earlier systematic literature review. Higher suicide ideation at 1 month following discharge was significantly related to a history of more than one previous suicide attempt and by the level of hopelessness reported by the participant during the hospital admission. Evidence of more than one Axis II disorder was significantly related to a reduced level of suicide ideation at 1-month follow-up. This finding seems in keeping with the knowledge that interpersonal life events are often found to be proximal triggers of suicidal behavior in Axis II patients and that these crises may be more likely to resolve over shorter time periods [47]. Being admitted for a current suicide attempt, being female and the level of depression severity were significantly related to scoring positive for suicide ideation at 1, 3 and 6 months

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postdischarge. Finally, suicide attempts and death by suicide within 6 months of discharge were predicted by being admitted for a current suicide attempt, living in a shelter prior to admission and the level of self-reported impulsivity during the baseline in-hospital assessment. Although deficits in emotional regulation have been conceptually related to selfharm and suicidal behavior, Taiminen et al. [48], similar to our findings, also demonstrated that the TAS was unrelated to suicide intention and inversely related to the lethality of attempts in a sample of hospitalized suicide attempters. All of these identified risk factors, history of recent attempts, level of depression, level of hopelessness and impulsivity are well-established risk factors for suicide [1]. However, the results serve as a reminder of the importance of characterizing the history of previous suicide behavior and are in keeping with the recent work of Runeson et al. [49] that confirmed how the nature of previous suicide attempts strongly predicted death by suicide in a large national cohort study. This research is felt to have some important clinical implications. As a selective preventive intervention may potentially be very impactful on the risk of suicide in the first weeks following discharge from an inpatient service, our findings suggest that a high-risk cohort should be readily identifiable during the course of a brief hospitalization. The prospective risk factors identified in this study, recent suicide attempts, levels of hopelessness, depression and impulsivity, are all clinically relevant and readily captured during an acute hospitalization. However, this research also underlines the importance of accurately documenting the history of previous suicide attempts and ideation. Malone et al. [50] reported on the shortcomings of clinical versus research assessments in documenting previous suicide attempts. In their findings, clinicians failed to document past suicide attempts in 24% of hospital patients at admission and in 28% of patients at discharge. Clearly, the practice of accurately utilizing this robust predictor of future risk of suicide, from previous suicide attempts, is a priority on all acute inpatient units. Finally, this research reinforces the need for inpatient units to adopt comprehensive discharge planning for high-risk patients such as those developed by Department of Veterans Affairs or the American Association of Suicidology [51]. The current study had several limitations that must be acknowledged. First, the study was carried out in a single, busy, large, inner city general hospital inpatient service, so the findings may not be generalizable to rural or smaller urban general hospital sites. Second, the sample attrition and incomplete assessments at 1-, 3- and 6-month follow-up restricted the sample available to test simultaneously multiple predictive variables. Third, in future research regarding risk factors in recently discharged patients, we would encourage the inclusion of more objective and subjective measures of the individuals' community support and of the quality of care provided on discharge from hospital. Lastly, although this study highlights the need for

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proper assessment of inpatients at high risk for suicide, our research did not address the important role of staff attitudes and how they impact the care of suicidal patients [52]. In summary, this prospective study of recently discharged psychiatric inpatients attests to the high risk for suicide attempts and suicide in the early months following discharge. The identification of high-risk cohorts for possible selective prevention strategies was supported based on the findings that well-known risk factors such as recent suicide attempts, levels of depression, hopelessness and impulsivity seem predictive of the future risk. This research was one part of a concurrent mixed-methods research project to develop a comprehensive model to explain suicides in recently discharge patients. The qualitative findings, separately reported [21,22], and these quantitative findings have led to the development of a preventive intervention with four core elements: the identification of high-risk patients, preparation for discharge to lessen the “angst and dread” of discharge, recognition of the continuing risk of suicide after discharge and the provision of increased support during the transition from inpatient status to the return to the community. Ultimately, the plan will be to test whether these four elements can deliver an effective preventive intervention to lessen the risk of suicide in recently discharged patients. Acknowledgments The research team wishes to offer their thanks to the Canadian Institutes for Health Research who generously supported this research. (Funding reference number - MOP 82835). References [1] Hawton K, van Heeringen K. Suicide. Lancet 2009;373(9672): 1372–81. [2] King EA, Baldwin DS, Sinclair JMA, Baker NG, Campbell M, Thompson C. The Wessex recent in-patient suicide study, 1. Case– control study of 234 recently discharged psychiatric patient suicides. Br J Psychiatry 2001;178:531–6. [3] King EA, Baldwin DS, Sinclair JMA, Campbell M. The Wessex recent in-patient suicide study, 2. Case–control study of 59 in-patient suicides. Br J Psychiatry 2001;178:537–42. [4] Pirkola S, Sohlman B, Wahlbeck K. The characteristics of suicides within a week of discharge after psychiatric hospitalization: a nationwide register study. BioMed Central Psychiatry 2005;5(32). [5] Troister T, Links P, Cutcliffe JR. Review of predictors of suicide within 1 year of discharge from a psychiatric hospital. Curr Psychiatry Rep 2008;10:60–5. [6] Yim PHW, Yip PSF, Li RHY, Dunn ELW, Yeung WS, Miao YK. Suicide after discharge from psychiatric inpatient care: a case–control study in Hong Kong. Aust N Z J Psychiatry 2004;38(1–2):65–72. [7] Goldacre M, Seagrott V, Hawton K. Suicide after discharge from psychiatric inpatient care. Lancet 1993;342:283–6. [8] Lawrence D, Holman CDJ, Jablensky AV, Fuller SA, Stoney AJ. Increasing rates of suicide in Western Australian psychiatric patients: a record linkage study. Acta Psychiatr Scand 2001;104:443–51. [9] Ho TP. The suicide risk of discharged psychiatric patients. J Clin Psychiatry 2003;64:702–7.

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