Inpatient psychiatrists in the United States deal with three
problems: suicide risk, aggression risk, and the inability care for oneself or
impaired functional capacity. Those have always been the primary reasons why
people are admitted to psychiatric hospitals. Over the past 30 years there has
been a problem with business intruding on these medical indications. Businesses
and or more specifically managed care companies eventually adopted a single
codeword “dangerousness”. Dangerousness was supposed to encompass all three of
the dimensions but eventually it developed a life of its own. As an example, I
have been asked by insurance company reviewers “Where’s the dangerousness?” whenever
they tried to throw one of my patients out of the hospital and onto the street.
Science or medical principles were not involved, just the economics of being
able to use a word to make money.
The reality of inpatient work is that the people there are
very high-risk for suicide, aggression, and premature death from multiple
causes. There was a study done in Germany about 20 years ago where they looked
at all-cause mortality of people discharged from psychiatric units five years
later and the number was very high. Post discharge suicide rates are much
higher than suicide rates in the general population. These high numbers are
expected because patients and inpatient units are selected for these traits
that predispose to higher mortality and morbidity. The trends have been complicated
by much shorter lengths of stay and bed limitations that means patients with
severe mental illness may be refused admission even if they clearly need it. As
example, since leaving the inpatient setting about 10 years ago, I have
attempted to refer severely ill patients to psychiatric hospitals and they were
turned away at the emergency department. In some cases they were turned away
without being seen by a physician. There are probably a handful of psychiatrists
in the United States who know the type of problem that needs to be treated that
inpatient units and I am one of them.
That situation makes a recent study on risk of suicide after
discharge from inpatient psychiatric care and interesting one. The study was
done in Sweden. It encompassed the years 1973 to 2009. During that time there
were 2,883,088 admissions and presumed discharges. 690,937 patients were
discharged more than once. Most the discharges were men (57.6%). There were no
explicit indications for admission. Patients were followed up and it was
determined that there were 3695 suicides within 30 days of discharge. The
authors calculated a suicide rate of 181/10,000. The discharge diagnosis most associated with
suicide with depression. They gave some rough estimates of the prevalence of
disorders in this population: 34% alcohol use disorder, 15.5% had mood
disorders and (bipolar disorder or depression) and 9.9% had schizophrenia.
Looking at the results according to diagnosis depression was
followed by reaction to crisis or what is probably called an adjustment
disorder in the US, but any specific psychiatric disorder and elevated hazard
ratio for suicide within the first 30 days of discharge relative to the
diagnosis of alcohol use disorder.
Suicide risk was also examined relative to recent suicidal
behavior. The suicidal behavior was considered to be any deliberate self-harm
less than 30 days prior to admission. That was noted to have a hazard ratio of
4.75. The diagnoses were re-examined in the context of deliberate self-harm
prior to admission and the risks were significantly higher in schizophrenia (HR
= 8.94) and other nonorganic psychosis (HR =6.82). Interested readers are referred to the full text
which is available free online for the specific details including hazard ratios
and confidence intervals for those hazard ratios.
The main findings of this study include the association of
relatively high risk at discharge for most diagnoses and much higher risk if a
specific diagnostic category was associated with a self-harm event 30 days
prior to admission. This confirms clinical risk assessments that
are typically done and also the fact that this is a high-risk population.
The authors do state that they regarded principal diagnosis at
discharge to be the best available information on the reason for admission. I
contacted the corresponding author about this and he did confirm that the
reasons for admission in Sweden are very similar to what they are in the United
States and that is suicide risk, aggression risk, and ability to care for
oneself - but those specific metrics were not listed in the paper.
The authors speculate on why the suicide risk is high. They
describe the slow recovery from depression and the clearing of psychomotor
retardation prior to the resolution of depressogenic thinking. In the US, psychiatrists are generally taught
that psychomotor retardation may reduce the risk of acting on suicidal thoughts
so that during treatment there may be a point where activation may put the
person at risk for acting on unresolved suicidal thoughts. Given the
characteristics of suicide particularly the impulsivity associated with it this
progression of events has never been proven and remains highly speculative. The
authors also had the interesting observation that crisis events or negative
life events are expected to offer good prognosis but this study showed men with
the diagnosis of reaction to a crisis were at high risk after discharge
irrespective of whether there was any recent suicidal behavior.
The authors review the strengths and limitations of the
study. The main strength is that it is a large-scale study with a significant
number of suicides. They also point out how their study has similarities with
other studies of suicide in hospitalized patients. On the limitation side most
of the limitations had to do with a lack of granularity in the data. I pointed
out the lack of specific admission indication in addition to diagnosis. In
current databases there may be metrics having to do with the level of suicide
or aggression risk. There are some large-scale studies being done on an
outpatient basis looking at those metrics as well as supportive interventions
based on risk scores.
The biological side was not discussed in this study even
though the database used probably contained all of the admission and discharge
medications. It would be interesting to know if certain pharmacological
interventions were more or less associated with suicides after discharge. It
would also be very useful to know if there were any protective factors from
inpatient treatment that could be discerned from the data both from the
standpoint of psychosocial interventions and biological interventions like
electroconvulsive therapy, transcranial magnetic stimulation, or treatment with
ketamine.
I have included a reference to another study of post discharge suicide rates done in a Medicare sample and with a slightly different methodology (2). In this case the researchers looked at a population of 770,643 patients with mental disorders compared with a 1,090,551 patients in a cohort with no mental disorders and compared suicide rates in the first 90 days after discharge. They found suicide rates that were 10-20 times higher in the mental disorder cohort. The non-mental disorder cohort had a rate that was lower than the baseline suicide rate in the US at the time (11.6 versus 14.2 per 100,00 person years). Like the Swedish study rates were the highest for mood disorders. Comparing both of these studies would be an interesting seminar for residents or journal club for staff psychiatrists interested in different epidemiological approaches to the same clinical problem. I have included two references by Chittaranjan Andrade, MD and encourage the use of his series on statistics and epidemiological concepts in the Journal of Clinical Psychiatry.
I have included a reference to another study of post discharge suicide rates done in a Medicare sample and with a slightly different methodology (2). In this case the researchers looked at a population of 770,643 patients with mental disorders compared with a 1,090,551 patients in a cohort with no mental disorders and compared suicide rates in the first 90 days after discharge. They found suicide rates that were 10-20 times higher in the mental disorder cohort. The non-mental disorder cohort had a rate that was lower than the baseline suicide rate in the US at the time (11.6 versus 14.2 per 100,00 person years). Like the Swedish study rates were the highest for mood disorders. Comparing both of these studies would be an interesting seminar for residents or journal club for staff psychiatrists interested in different epidemiological approaches to the same clinical problem. I have included two references by Chittaranjan Andrade, MD and encourage the use of his series on statistics and epidemiological concepts in the Journal of Clinical Psychiatry.
From a clinical standpoint, the take-home message for
clinicians is to make sure that deliberate self-harm prior to admission and the
diagnosis are carefully explored. It is fairly common practice to consider
adjustment disorders to be low risk in terms of brief hospital stays and
discharge plans that do not include intensive outpatient treatment. This study
suggests that at least some of those patients need more intensive intervention
but there is no guidance on how to identify that group. The other high-risk
groups of patients with psychosis that had deliberate self-harm prior to
admission and any trained inpatient psychiatrist should admit those patients
and treat them until there is clinical improvement that results in decreased
risk.
My only concern about the current patient flow through
emergency departments and onto psychiatric inpatient units is that many of
these patients never get admitted and if they do they are discharged in a short
period of time with the same symptoms that they presented with. The inpatient environments in the US are also
deteriorated to the point that they resemble correctional settings and patients
want to leave as soon as possible.
These are not good ways to address the issue of post hospitalization
suicide risk in a high risk population.
George Dawson, MD, DFAPA
Reference:
2: Olfson M, Wall M, Wang S, Crystal S, Liu SM, Gerhard T, Blanco C. Short-termSuicide Risk After Psychiatric Hospital Discharge. JAMA Psychiatry. 2016 Nov 1;73(11):1119-1126. doi: 10.1001/jamapsychiatry.2016.2035. PubMed PMID: 27654151. (full text)
3: Andrade C. Why odds ratios can be tricky statistics: the case of finasteride, dutasteride, and sexual dysfunction. J Clin Psychiatry.2018;79(6): 18f12641. Link
4: Andrade, Chittaranjan. Drug interactions in the treatment of depression in patients with ischemic heart disease. The Journal of Clinical Psychiatry 73.12 (2012): 1475-1477.
