July 8, 2019 – Suicide and attempt rates are greatly elevated among patients after discharge from psychiatric hospitalization – especially during the first year after discharge, concludes a research review in the July/August issue of Harvard Review of Psychiatry. The journal is published in the Lippincott portfolio by Wolters Kluwer.
Rates of suicide and attempts soon after hospital discharge are far higher than in the general population, and even higher than in clinical samples of patients with similar psychiatric disorders. "[The] findings underscore the need for improved monitoring and care of patients discharged from psychiatric hospitalization," according to the new report. The study authors were Alberto Forte, MD, Andrea Buscajoni, MD, and Maurizio Pompili, MD, PhD, of Sapienza University of Rome, Italy; Andrea Fiorillo, MD, PhD, of University of Campania Luigi Vanvitelli, Naples; and Ross J. Baldessarini, MD, Director of the International Consortium for Bipolar & Psychotic Disorders Research of the Mailman Research Center at McLean Hospital in Belmont, Mass.
Better Follow-up Needed to Prevent Suicide after Psychiatric Discharge
The review assembled the best available evidence on the risk of suicidal events after discharge from psychiatric hospitalization. It included data on 1.7 million patients, drawn from 48 studies published between 1964 and 2017 and providing at least 12 months of follow-up after discharge.
Based on data from 41 studies, the rate of suicide within 12 months of discharge was 2.41 per 1,000 psychiatric discharges, or about one suicide for every 415 discharges. In six studies reporting on both outcomes, the rate of attempted suicides was nearly nine times higher than the rate of completed suicides. This rate indicates that risk of a suicide attempt after discharge would be about one for every 46 discharges, according to the authors.
Dr. Forte and his collaborators comment: "If we consider a 30-bed inpatient unit with a 10-day average length of stay, this means 36.5 discharges per bed, or a total of 1,095 total discharges from the service in a year. That number of discharges should yield about 24 suicide attempts (1,095/46) and nearly three suicides within 12 months after discharge, or at least two suicidal events following each month's discharges."
Across all 48 studies, the risk of suicidal acts was highest soon after patients left the hospital. "More than one-quarter of all suicidal acts (26%) arose within the first month after discharge, over 40% within three months, and 73% within one year," Dr. Forte and coauthors write.
The pooled rate of suicides following psychiatric hospital discharge was more than 20 times higher than in the general population, and higher than in large clinical samples of comparable, but not necessarily recently hospitalized, patients. Although this estimate is high, it is much lower than in previous studies that included shorter follow-up, which may overestimate the annual risk of suicidal events. Risks of suicide attempts following hospital discharge had not been reported previously.
The report draws attention to the very high suicide rates in the first few months after discharge from psychiatric hospitalization. "[T]his period of early post-discharge suicidal risk calls for especially close clinical support and monitoring of patients at risk," the researchers write. The quality, promptness, and continuity of aftercare likely play a crucial role in patient outcomes.
Dr. Forte and colleagues highlight the importance of having a reliable plan for post-discharge care, along with better assessment of suicidal risk before patients leave the hospital, especially if suicide was a concern leading to hospitalization. They conclude: "Ideally, planning and implementing of post-discharge care should occur prior to discharge and pursued without delay into aftercare, with clinicians remaining especially alert to elevated suicidal risk for at least several months."
About the Harvard Review of Psychiatry
The Harvard Review of Psychiatry is the authoritative source for scholarly reviews and perspectives on a diverse range of important topics in psychiatry. Founded by the Harvard Medical School Department of Psychiatry, the journal is peer reviewed and not industry sponsored. It is the property of Harvard University and is affiliated with all of the Departments of Psychiatry at the Harvard teaching hospitals. Articles encompass major issues in contemporary psychiatry, including neuroscience, epidemiology, psychopharmacology, psychotherapy, history of psychiatry, and ethics.
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