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Psychiatric hospitalizations during the last 12 months before suicide
General Hospital Psychiatry 29 (2007) 63 – 65
Short Communications
Psychiatric hospitalizations during the last 12 months before suicide Eberhard A. Deisenhammer, M.D.4, Michael Huber, Georg Kemmler, Ph.D., Elisabeth M. Weiss, M.D., Ph.D., Hartmann Hinterhuber, M.D. Department of General Psychiatry, Innsbruck Medical University, Innsbruck, Austria Received 20 July 2006; accepted 22 September 2006
Abstract Objectives: Suicide victims frequently have had contact with the mental health care system before they died. In this study, the rates, numbers and lengths of psychiatric hospitalizations of suicide victims during the last year before their suicide commission were assessed. Methods: The quarterly and monthly hospitalization rates during the last 12 months of 665 individuals who committed suicide were compared. Results: Of the suicide victims, 16.4% had been hospitalized at least once. The period after a recent discharge bore the highest risk for suicide commission, with 4.7% (28.4% of those hospitalized) committing suicide within 1 week after their discharge and 7.8% (47.7%) committing suicide within 1 month. Hospitalization rates were significantly higher in the last 3 months as compared with the preceding quarters. Conclusion: Increasing utilization of inpatient treatment facilities should prompt a particularly profound suicide risk assessment and postdischarge treatment planning. D 2007 Elsevier Inc. All rights reserved. Keywords: Suicide risk; Hospital admission; Mental health care system
1. Introduction
2. Methods
Mental illness is a major risk factor for suicide [1]. A significant portion of suicide victims have had contact with the health care system before they died, with varying rates according to whether general practitioners (GPs), psychiatrists or hospitalizations are studied [2,3]. Seeking contact with the health care system may be conceptualized as a cry for help by an individual experiencing a suicidal crisis. However, suicidality is not regularly reported during a contact [4–6]. The contact patterns of suicide victims with the health care system during the last time before they died may provide useful clues for the assessment of current suicide risks. In this study, rates and numbers of psychiatric hospitalizations of suicide victims during the last year before they died were assessed.
The study sample comprised all suicides committed in Tyrol, Austria, between October 1, 1996, and September 30, 2002. Data on these suicides were obtained from the Tyrol Suicide Register. For this scientific register, various data concerning each victim and the circumstances of every suicide committed in Tyrol are assessed by a police officer. During the study period, two psychiatric hospitals and one psychiatric unit within a general hospital existed in the region. The allocation of patients requiring psychiatric inpatient treatment in a facility is strictly organized, thus making it unlikely that patients residing in Tyrol are hospitalized outside the state. Suicide victim data were linked with the hospitals’ registers. Numbers and lengths of hospitalizations within the last 12 months before suicide commissions were extracted. Statistical comparisons between the individual 3-month periods were made using the Friedman test and subsequent Wilcoxon matched-pairs tests. The latter measure was also used for comparisons between the last month and the mean of the preceding 2 months.
4 Corresponding author. Tel.: +43 512 504 81612. E-mail address: [email protected] (E.A. Deisenhammer). 0163-8343/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2006.09.007
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E.A. Deisenhammer et al. / General Hospital Psychiatry 29 (2007) 63 – 65
3. Results During the study period, 710 suicides occurred in Tyrol (mean annual suicide rate, 17.5/100,000). Forty-five suicide victims were excluded from our analysis because either of incomplete data or the place of their residence was outside Tyrol, leaving 665 subjects for analysis. Of these, 489 (73.5%) were males. Mean age was 48.7 years. According to police assessments, 309 suicide victims (46.5%) had currently been in contact with a GP and 97 (14.6%) had a history of attempting suicides. One hundred nine suicide victims (16.4%) had been hospitalized at least once in a psychiatric inpatient facility within the last year before their suicide commission. Of these, 40 had one hospitalization, 24 had two hospitalizations, 17 had three hospitalizations and 28 had more than three hospitalizations during the observation period. Fourteen suicides (by 2.1% of the total population and 12.8% of those hospitalized) occurred on the day of the patients’ discharge, 31 (4.7% and 28.4%, respectively) occurred within 7 days after discharge and 52 (7.8% and 47.7%, respectively) occurred within 1 month after discharge. Fig. 1 shows the percentages of suicide victims hospitalized at least once, the mean number of hospitalizations and the mean number of days spent in a psychiatric hospital/unit per quarter. For all three variables, the respective values were significantly higher in the last 3-month period than in the preceding quarters. This was true for both the male and female subjects. Mean hospitalization number was also significantly higher in the last month before suicide commission than the monthly means of the preceding 2 months. In Fig. 2, percentages of suicides related to time after discharge are shown. 4. Discussion The analysis of three hospitalization indices revealed significantly higher hospitalization rates, numbers and days for the last 3 months before suicide commission as
Fig. 1. Rates of suicide victims hospitalized at least once, mean number of hospitalizations and mean number of days spent under psychiatric inpatient care during the last 12 months before suicide commission.
Fig. 2. Cumulative distribution of suicides related to time elapsed after discharge.
compared with those for the preceding quarters and the highest hospitalization number for the last month. Although the actual circumstances and reasons for the hospital admissions are unknown, several explanations for the increased hospital care utilization before suicide commission are possible. Mental disorder is present in about 90% of suicide victims [7,8], and an exacerbation may have led to hospitalization. Suicide attempts are well-known precursors of completed suicides, and the risk for completion is particularly high shortly after an attempt [9]. Whether the hospitalization was driven by the patients or their extramural doctors, the increased utilization of psychiatric inpatient treatment reflects an increased need for professional support in mental crises and may be interpreted as a louder cry for help by psychiatric patients. Studies focusing on outpatient facilities found a similar increase in contact frequencies during the months before the suicidal act for suicide completers [10,11] and attempters [12,13]. The finding that a considerable portion of the suicides occurred within 1 week after discharge confirms prior results of a particularly high risk for suicide commission shortly after discharge [14–17]. Obviously, there are still unmet needs in terms of risk assessment at discharge and adequate planning of multidisciplinary posttreatment when patients are switched from hospital care to outpatient treatment. Enhanced communication between physicians, discharge of patients only with a scheduled outpatient appointment and involving the social support potential of families and professional helpers should be considered within this context. Periods of increased utilization of psychiatric inpatient treatment constitute high-risk periods preceding a suicidal act and should prompt a particularly profound suicide risk assessment and postdischarge treatment planning.
References [1] Harris EC, Barraclough B. Suicide as an outcome for mental disorders. Br J Psychiatry 1997;170:205 – 28.
E.A. Deisenhammer et al. / General Hospital Psychiatry 29 (2007) 63 – 65 [2] Pirkis J, Burgess P. Suicide and recency of health care contacts. A systematic review. Br J Psychiatry 1998;173:462 – 74. [3] Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 2002;159:909 – 16. [4] Isomets7 ET, Heikkinen ME, Marttunen MJ, Henriksson MM, Aro HM, Lfnnqvist JK. The last appointment before suicide: is suicide intent communicated? Am J Psychiatry 1995;152:919 – 22. [5] Busch KA, Fawcett J, Jacobs DG. Clinical correlates of inpatient suicide. J Clin Psychiatry 2003;64:14 – 9. [6] Dong JYS, Ho TP, Kan CK. A case–control study of 92 cases of inpatient suicides. J Affect Disord 2005;87:91 – 9. [7] Lesage AD, Boyer R, Grunberg F, Vanier C, Morissette R, Me´nardButeau C, et al. Suicide and mental disorders: a case–control study of young men. Am J Psychiatry 1994;151:1063 – 8. [8] Conwell Y, Duberstein PR, Cox C, Herrmann JH, Forbes NT, Caine ED. Relationships of age and Axis I diagnoses in victims of completed suicide: a psychological autopsy study. Am J Psychiatry 1996;153: 1001 – 8. [9] Cooper J, Kapur N, Webb R, Lawlor M, Guthrie E, Mackway-Jones K, et al. Suicide after deliberate self-harm: a 4-year cohort study. Am J Psychiatry 2005;162:297 – 303.
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[10] Appleby L, Amos T, Doyle U, Tomenson B, Woodman M. General practitioners and young suicides. A preventive role for primary care. Br J Psychiatry 1996;168:330 – 3. [11] Andersen UA, Andersen M, Rosholm JU, Gram LF. Contacts to the health care system prior to suicide: a comprehensive analysis using registers for general and psychiatric hospital admissions, contacts to general practitioners and practising specialists and drug prescriptions. Acta Psychiatr Scand 2000;102:126 – 34. [12] Michel K, Runeson B, Valach L, Wasserman D. Contacts of suicide attempters with GPs prior to the event: a comparison between Stockholm and Bern. Acta Psychiatr Scand 1997;95:94 – 9. [13] Suominen KH, Isomets7 ET, Ostamo AI, Lfnnqvist JK. Health care contacts before and after attempted suicide. Soc Psychiatry Psychiatr Epidemiol 2002;37:89 – 94. [14] Goldacre MJ, Seagroatt V, Hawton K. Suicide after discharge from psychiatric inpatient care. Lancet 1993;342:283 – 6. [15] Ho TP. The suicide risk of discharged psychiatric patients. J Clin Psychiatry 2003;64:702 – 7. [16] Hbyer EH, Olesen AV, Mortensen PB. Suicide risk in patients hospitalised because of an affective disorder: a follow-up study, 1973–1993. J Affect Disord 2004;78:209 – 17. [17] Qin P, Nordentoft M. Suicide risk in relation to psychiatric hospitalization. Arch Gen Psychiatry 2005;62:427 – 32.
Short Communications
Psychiatric hospitalizations during the last 12 months before suicide Eberhard A. Deisenhammer, M.D.4, Michael Huber, Georg Kemmler, Ph.D., Elisabeth M. Weiss, M.D., Ph.D., Hartmann Hinterhuber, M.D. Department of General Psychiatry, Innsbruck Medical University, Innsbruck, Austria Received 20 July 2006; accepted 22 September 2006
Abstract Objectives: Suicide victims frequently have had contact with the mental health care system before they died. In this study, the rates, numbers and lengths of psychiatric hospitalizations of suicide victims during the last year before their suicide commission were assessed. Methods: The quarterly and monthly hospitalization rates during the last 12 months of 665 individuals who committed suicide were compared. Results: Of the suicide victims, 16.4% had been hospitalized at least once. The period after a recent discharge bore the highest risk for suicide commission, with 4.7% (28.4% of those hospitalized) committing suicide within 1 week after their discharge and 7.8% (47.7%) committing suicide within 1 month. Hospitalization rates were significantly higher in the last 3 months as compared with the preceding quarters. Conclusion: Increasing utilization of inpatient treatment facilities should prompt a particularly profound suicide risk assessment and postdischarge treatment planning. D 2007 Elsevier Inc. All rights reserved. Keywords: Suicide risk; Hospital admission; Mental health care system
1. Introduction
2. Methods
Mental illness is a major risk factor for suicide [1]. A significant portion of suicide victims have had contact with the health care system before they died, with varying rates according to whether general practitioners (GPs), psychiatrists or hospitalizations are studied [2,3]. Seeking contact with the health care system may be conceptualized as a cry for help by an individual experiencing a suicidal crisis. However, suicidality is not regularly reported during a contact [4–6]. The contact patterns of suicide victims with the health care system during the last time before they died may provide useful clues for the assessment of current suicide risks. In this study, rates and numbers of psychiatric hospitalizations of suicide victims during the last year before they died were assessed.
The study sample comprised all suicides committed in Tyrol, Austria, between October 1, 1996, and September 30, 2002. Data on these suicides were obtained from the Tyrol Suicide Register. For this scientific register, various data concerning each victim and the circumstances of every suicide committed in Tyrol are assessed by a police officer. During the study period, two psychiatric hospitals and one psychiatric unit within a general hospital existed in the region. The allocation of patients requiring psychiatric inpatient treatment in a facility is strictly organized, thus making it unlikely that patients residing in Tyrol are hospitalized outside the state. Suicide victim data were linked with the hospitals’ registers. Numbers and lengths of hospitalizations within the last 12 months before suicide commissions were extracted. Statistical comparisons between the individual 3-month periods were made using the Friedman test and subsequent Wilcoxon matched-pairs tests. The latter measure was also used for comparisons between the last month and the mean of the preceding 2 months.
4 Corresponding author. Tel.: +43 512 504 81612. E-mail address: [email protected] (E.A. Deisenhammer). 0163-8343/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2006.09.007
64
E.A. Deisenhammer et al. / General Hospital Psychiatry 29 (2007) 63 – 65
3. Results During the study period, 710 suicides occurred in Tyrol (mean annual suicide rate, 17.5/100,000). Forty-five suicide victims were excluded from our analysis because either of incomplete data or the place of their residence was outside Tyrol, leaving 665 subjects for analysis. Of these, 489 (73.5%) were males. Mean age was 48.7 years. According to police assessments, 309 suicide victims (46.5%) had currently been in contact with a GP and 97 (14.6%) had a history of attempting suicides. One hundred nine suicide victims (16.4%) had been hospitalized at least once in a psychiatric inpatient facility within the last year before their suicide commission. Of these, 40 had one hospitalization, 24 had two hospitalizations, 17 had three hospitalizations and 28 had more than three hospitalizations during the observation period. Fourteen suicides (by 2.1% of the total population and 12.8% of those hospitalized) occurred on the day of the patients’ discharge, 31 (4.7% and 28.4%, respectively) occurred within 7 days after discharge and 52 (7.8% and 47.7%, respectively) occurred within 1 month after discharge. Fig. 1 shows the percentages of suicide victims hospitalized at least once, the mean number of hospitalizations and the mean number of days spent in a psychiatric hospital/unit per quarter. For all three variables, the respective values were significantly higher in the last 3-month period than in the preceding quarters. This was true for both the male and female subjects. Mean hospitalization number was also significantly higher in the last month before suicide commission than the monthly means of the preceding 2 months. In Fig. 2, percentages of suicides related to time after discharge are shown. 4. Discussion The analysis of three hospitalization indices revealed significantly higher hospitalization rates, numbers and days for the last 3 months before suicide commission as
Fig. 1. Rates of suicide victims hospitalized at least once, mean number of hospitalizations and mean number of days spent under psychiatric inpatient care during the last 12 months before suicide commission.
Fig. 2. Cumulative distribution of suicides related to time elapsed after discharge.
compared with those for the preceding quarters and the highest hospitalization number for the last month. Although the actual circumstances and reasons for the hospital admissions are unknown, several explanations for the increased hospital care utilization before suicide commission are possible. Mental disorder is present in about 90% of suicide victims [7,8], and an exacerbation may have led to hospitalization. Suicide attempts are well-known precursors of completed suicides, and the risk for completion is particularly high shortly after an attempt [9]. Whether the hospitalization was driven by the patients or their extramural doctors, the increased utilization of psychiatric inpatient treatment reflects an increased need for professional support in mental crises and may be interpreted as a louder cry for help by psychiatric patients. Studies focusing on outpatient facilities found a similar increase in contact frequencies during the months before the suicidal act for suicide completers [10,11] and attempters [12,13]. The finding that a considerable portion of the suicides occurred within 1 week after discharge confirms prior results of a particularly high risk for suicide commission shortly after discharge [14–17]. Obviously, there are still unmet needs in terms of risk assessment at discharge and adequate planning of multidisciplinary posttreatment when patients are switched from hospital care to outpatient treatment. Enhanced communication between physicians, discharge of patients only with a scheduled outpatient appointment and involving the social support potential of families and professional helpers should be considered within this context. Periods of increased utilization of psychiatric inpatient treatment constitute high-risk periods preceding a suicidal act and should prompt a particularly profound suicide risk assessment and postdischarge treatment planning.
References [1] Harris EC, Barraclough B. Suicide as an outcome for mental disorders. Br J Psychiatry 1997;170:205 – 28.
E.A. Deisenhammer et al. / General Hospital Psychiatry 29 (2007) 63 – 65 [2] Pirkis J, Burgess P. Suicide and recency of health care contacts. A systematic review. Br J Psychiatry 1998;173:462 – 74. [3] Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 2002;159:909 – 16. [4] Isomets7 ET, Heikkinen ME, Marttunen MJ, Henriksson MM, Aro HM, Lfnnqvist JK. The last appointment before suicide: is suicide intent communicated? Am J Psychiatry 1995;152:919 – 22. [5] Busch KA, Fawcett J, Jacobs DG. Clinical correlates of inpatient suicide. J Clin Psychiatry 2003;64:14 – 9. [6] Dong JYS, Ho TP, Kan CK. A case–control study of 92 cases of inpatient suicides. J Affect Disord 2005;87:91 – 9. [7] Lesage AD, Boyer R, Grunberg F, Vanier C, Morissette R, Me´nardButeau C, et al. Suicide and mental disorders: a case–control study of young men. Am J Psychiatry 1994;151:1063 – 8. [8] Conwell Y, Duberstein PR, Cox C, Herrmann JH, Forbes NT, Caine ED. Relationships of age and Axis I diagnoses in victims of completed suicide: a psychological autopsy study. Am J Psychiatry 1996;153: 1001 – 8. [9] Cooper J, Kapur N, Webb R, Lawlor M, Guthrie E, Mackway-Jones K, et al. Suicide after deliberate self-harm: a 4-year cohort study. Am J Psychiatry 2005;162:297 – 303.
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[10] Appleby L, Amos T, Doyle U, Tomenson B, Woodman M. General practitioners and young suicides. A preventive role for primary care. Br J Psychiatry 1996;168:330 – 3. [11] Andersen UA, Andersen M, Rosholm JU, Gram LF. Contacts to the health care system prior to suicide: a comprehensive analysis using registers for general and psychiatric hospital admissions, contacts to general practitioners and practising specialists and drug prescriptions. Acta Psychiatr Scand 2000;102:126 – 34. [12] Michel K, Runeson B, Valach L, Wasserman D. Contacts of suicide attempters with GPs prior to the event: a comparison between Stockholm and Bern. Acta Psychiatr Scand 1997;95:94 – 9. [13] Suominen KH, Isomets7 ET, Ostamo AI, Lfnnqvist JK. Health care contacts before and after attempted suicide. Soc Psychiatry Psychiatr Epidemiol 2002;37:89 – 94. [14] Goldacre MJ, Seagroatt V, Hawton K. Suicide after discharge from psychiatric inpatient care. Lancet 1993;342:283 – 6. [15] Ho TP. The suicide risk of discharged psychiatric patients. J Clin Psychiatry 2003;64:702 – 7. [16] Hbyer EH, Olesen AV, Mortensen PB. Suicide risk in patients hospitalised because of an affective disorder: a follow-up study, 1973–1993. J Affect Disord 2004;78:209 – 17. [17] Qin P, Nordentoft M. Suicide risk in relation to psychiatric hospitalization. Arch Gen Psychiatry 2005;62:427 – 32.