A Fundamental Gap in Suicide Prevention: Aftercare Post Discharge from Psychiatric Hospitalization for Suicide Ideation and Attempt
Sophia G. SchmidtAdvisor: Dr. Holly C. WilcoxJHSPH CapstoneAugust 8, 2011
Presentation Outline
Scenario Methods Magnitude Background Conceptual framework Discussion Gaps and Limitations Conclusion
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Scenario
Imagine… Being hospitalized
having seriously considered or attempted suicide
Having a psychiatric disorder at the same time
Being discharged from the psychiatric hospital only 7 days after ideation or attempt
Would you be fully recuperated?
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Literature Review Methods
Population: Patients post discharge from short-term hospitalizations after suicide events
Methods: 26 studies from the published literature Analyzed for:
Problem causes and determinants Epidemiology Prevalence Public Health Relevance Prevention Intervention 4
Suicide Magnitude in the United States
11th leading cause of death in people over the age of 10 (2006)
Age-adjusted mortality rate of 11.27 per 100,000 (2007)
Suicide kills almost twice as many as homicide (2007)
Significant cause of Years of Life Lost (2007)
Economic costs are estimated to be $11.8 billion in lost income (2002) not including medical expenses or decreased productivity of suicide ideators or of grieving family and friends.
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Suicide Prevention Timeline Part 1
Over the past century, treatment has shifted from secure hospital environments to less secure community care
Over the past 50 years, the US mortality rate from suicide (not age-adjusted) has barely changed
1950s,1960s: Treated medically and sent home
1958: Los Angeles Suicide Prevention Center opens
1964: Working Conference on Suicide Prevention in Copenhagen said that suicide would be controlled with a “persistent and well-considered campaign against it”
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Suicide Prevention Timeline Part 2
1966: Center for Studies of Suicide Prevention established by US Government at NIMH (Now the Suicide Research Consortium)
1999: Surgeon General’s Call to Action on Suicide was published
2000s: 2001: DHHS publishes the National Strategy for
Suicide Prevention 2002: IOM report titled, “Reducing Suicide: A
National Imperative” Healthy People 2010 Healthy People 2020
In the past two decades, significant progress has been made on suicide prevention
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Cognitive Model of Suicidal Behavior Part 1
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Cognitive Model of Suicidal Behavior Part 2
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Primary risk factors for suicide post discharge
Major risk factors for suicide: Previous suicide attempt Current suicide ideation Psychiatric disorder
Other fundamental contributing factors to suicide post discharge include: Returning to an unsupportive environment Being placed on an activating/agitating new
medication Having the energy to complete the previously
considered suicide
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Other Contributing risk factors
Impulsivity Premature discharge Self-discharge Longer notations in medical charts during
hospitalization Reduction of support and supervision Reduction in care prior to the suicide
event Shame Reaction or Stigma Living alone Socially isolated Lack social support Life Stress and the inability to cope 11
Psychiatric risk factor
90% of suicide deaths were individuals suffering from psychiatric disorders. Affective disorders
are most common in suicide deaths
Important to note that most people suffering from psychiatric disorders never attempt suicide
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Release from hospital risk factor
Patients recently released from a psychiatric hospital are at high risk for suicide
Suicide post-discharge is hard to predict. It has been variably estimated that post-
discharge suicide is most likely within: A few days First 28 days First 3 months First 4 years
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Aftercare is a complex phenomenon
Continuity of Care is very important Prevention
Prior to discharge Discharge coordinators and planning Diagnosis and stabilization Education (for everyone involved) Assessment of risk factors
During the discharge period Assessment of post-discharge risk
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Aftercare is a complex phenomenon, cont.
Prevention, cont. Following discharge
Day hospital/partial hospitalization Psychotherapy Medication management Close follow-up Connection with services Engagement in community “Green Card” with emergency
contacts Outpatient Commitment
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Gaps and Limitations
Gaps in existing literature: Additional studies on various related topics Study effectiveness of health services
Limitations Statistics limitations: death reporting Magnitude limitation: counting suicide attempts Study limitations:
Generalizability of studies completed in different countries
Retrospective case notes not designed for study
Non-retrospective studies have few subjects Not possible to study “no treatment” group
ethically High possibility of death during studies 16
Conclusion
Suicide post-discharge from a short-term psychiatric hospitalization is a serious public health problem.
Although prevention and intervention relating to education, support, and clinical care have improved in the past two decades, there is still more research required to fill the gaps.
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Questions?
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References American Psychiatric Association. (2003). Practice Guideline for the Assessment and Treatment of Patients with
Suicidal Behaviors. Retrieved from http://www.psychiatryonline.com/pracGuide/pracGuideChapToc_14.aspx Appleby L., Dennehy J., Thomas C., Fargher E., Lewis G. (1999a) Aftercare and Clinical characteristics of people with
mental illness who commit suicide: a case-control study. The Lancet., 353, 1397-1400. Appleby L., Shaw J., Amos T., McDonnel R., Harris C., McCann K., Kienan K., Savies S., Bickley H., Parsons R. (1999b)
Suicide within 12 months of contact with mental health services: national clinical survey. BMJ, 318, 1235-1239. Appleby L. (2000). Safer Services: conclusions from the report of the National Confidential Inquiry. Advances in
Psychiatric Treatment, 6, 5-15. Appelbaum, P.S. (2001). Thinking Carefully about Outpatient Commitment. Psychiatric Services, 52(3), 347-350. Baroff L.J., Janowicz N., Asarnow J.R. (2006) Survey of California Emergency Departments about Practices for
Management of Suicidal Patients and Resources Available for their care. Annals of Emergency Medicine, 48(4), 452-458
Bauer, H. (1953). Suicide and Public Health. California Medicine, 79(6), 422-424. Beautrais, A.L., Joyce, P.R., Mulder, R.T., Fergusson, D.M., Deavoll, B.J., & Nightingale, S.K. (1996) Prevalence and
Comorbidity of Mental Disorders in Persons Making Serious Suicide Attempts: A Case-Control Study. Am J Psychiatry, 153(8), 1009-1014.
Beautrais, A.L., Fergusson, D, Coggan, C, Collings, C, Doughty, C, Ellis, et al. (2007). Effective Strategies for suicide prevention in New Zealand: a review of the evidence. The New Zealand Medical Journal, 120(1251). Retrieved from http://www.nzma.org.nz/journal/120-1251/2459
Bridge, S. (2006). Suicide Prevention: Targeting the patient at risk. Australian Family Physician, 35(5), 335-338. Cedereke M., Monti K., Öjehagen A. (2007) Telephone contact with patients in the year after a suicide attempt: does
it affect treatment attendance and outcome? A randomized controlled study. Eur Psychiatry, 17, 82-91. Cedereke, M. and Öjehagen, A. (2002). Patients’ needs during the year after a suicide attempt: A secondary analysis
of a randomized controlled intervention study. Soc Psychiatry Psychiatr Epidemiol, 37, 357-363. Centers for Disease Control and Prevention (CDC). (2007) FastStats – Mental. Retrieved on July 17, 2011 from:
http://www.cdc.gov/nchs/fastats/mental.htm Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC). Web-
based Injury Statistics Query and Reporting System (WISQARS). Retrieved on July 16, 2011 from: http://www.cdc.gov/injury/wisqars/index.html
Comer R.J. (2002). Fundamentals of Abnormal Psychology. New York: Worth Publishers. Crawford M.J. (2004) Suicide Following discharge from in-patient psychiatric care. Advances in Psychiatric
Treatment, 10, 434-438. Crocetti, G.M. (1959). Suicide and Public Health – An attempt at reconceptualization. American Journal of Public
Health, 49(7), 881-887. Dennehy, J.A., Appleby, L., Thomas, C.S., Faragher, E.B. (1996). Case Control Study of suicide by discharged
psychiatric patients. BMJ, 312, 1580.19
References Dublin, L.I. (1965). Suicide: A Public Health Problem. American Journal of Public Health, 55(1), 12-15. Geddes J.R.& Jusczak, E. (1995) Period Trends in rate of suicide in first 28 days after discharge from psychiatric hospital in
Scotland, 1968-1992. BMJ, 311, 357-360 Goldacre M,, Seagroatt V, Hawton, K. (1993) Suicide after discharge from psychiatric inpatient care. The Lancet, 342,
283-286. Goldsmith S.K., Pellmar T.C., Kleinman A.M., Bunney W.E. (eds). (2002). Reducing Suicide: A National Imperative.
Washington, D.C.: The National Academies Press. Gould, M.S., Kalafat, J., HarrisMunfakh, J.L, & Kleinman, M. (2007). An Evaluation of Crisis Hotline Outcomes Part 2:
Suicidal Callers. Suicide and Life-Threatening Behavior, 37(3), 338-352. Greer S., Bagley C. (1971). Effect of Psychiatric Intervention in Attempted Suicide: A Controlled Study. British Medical
Journal, 1, 310-312. Gunnell D., Hawton K., Ho D, Evans J., O’Connor S., Potokar J., Donovan J. (2008) Hospital admissions for self-harm after
discharge from psychiatric inpatient care: cohort study. BMJ, 337, a2278. Hawton K., van Heeringen K.. (2009) Suicide. The Lancet, 373, 1372-1381. Holley H.L., Fick G., Love E.J. (1998) Suicide following an inpatient hospitalization for a suicide attempt: A Canadian
follow-up study. Soc Psychiatry Psychiatr Epidemiol, 33, 543-551. Hunt, I.M., Kapur, N., Webb, R., Robinson, J., Burns, J., Shaw, J., Appleby, L. Suicide in recently discharged psychiatric
patients: a case-control study. Psychological Medicine. 39:443-449. Jamison K.R. Suicide and bipolar disorder. (2000) J Clin Psychiatry, 61, Suppl 9, 47-51. Kan C.K., Ho T.P., Dong J.Y.S., Dunn, E.L.W. (2007) Risk Factors for suicide in the immediate post discharge period. Soc
Psychiatry Psychiatr Epidemiol, 42, 208-214. King E.A., Baldwin .D.S, Sinclair J.M.A., Campbell M.J. (2001) The Wessex Recent In-Patient Suicide Study, 1: Case-control
study of 234 recently discharged psychiatric patient suicides. British Journal of Psychiatry, 178, 531-536. Lin H.C., Lee H.S., Kuo, N.W., Chu, C.H. (2008) Hospital characteristics associated with post discharge suicide of severely
depressed patients. Journal of Affective Disorders, 110, 215-221. Mann J.J. (2002) A Current Perspective of Suicide and Attempted Suicide. Annals of Internal Medicine, 136, 302-311. Mann J.J.. (2003) Neurobiology of suicidal behavior. Nat Rev Neurosci. 1, 819-288. Mann, J.J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A., et al. (2005). Suicide Prevention Strategies: A
Systematic Review. JAMA, 294(16), 2064-2074. McKenzie I. & Wurr K. (2001) Early Suicide Following Discharge from a Psychiatric Hospital. Suicide and Life-Threatening
Behavior, 31(3), 358-363. McNamee, J.E. and Offord, D.R. (1990). Prevention of Suicide. Can Med Assoc J, 142(11), 1223-1230. Möller H.J. (1989). Efficacy of different strategies of aftercare for patients who have attempted suicide. Journal of the
Royal Society of Medicine, 82, 643-647. Montgomery S.A., Roy D., Montgomery D.B. (1983) The Prevention of Recurrent Suicidal Acts. British Journal of Clinical
Pharmacology, 15, 183S-188S. 20
References Qin P. & Nodentoft M. (2005) Suicide Risk in Relation to Psychiatric Hospitalization: Evidence Based on Longitudinal
Registers. Arch Gen Psychiatry, 62, 427-432. Reid, W.H. (2009). Prognosis After Suicide Attempt: Standard of Care and the Consequences of Not Meeting It. Journal of
Psychiatric Practice, 15(2), 141-144. Rihmer, Z. (2007). Suicide Risk in Mood Disorders. Curr Opin Psychiatry, 20(17), 17-22. Rihmer, Z., Belsõ, N, & Kiss, K. (1995). Strategies for suicide prevention. Curr Opin Psychiatry, 15, 83-87. Schmidt, S. (2009). Suicide risk post discharge from in-patient Psychiatric Hospitalization. Suicide as a Public Health
Problem JHSPH course. Spring 2009. Shneidman, E.S. & Farberow, N.L. (1965). The Los Angeles Suicide Prevention Center: A Demonstration of Public Health
Feasibilities. American Journal of Public Health, 55(1), 21-26. Skeem J.L., Silver E., Appelbaum P.S., Tiemann J. (2006) Suicide-Related Behavior after Psychiatric Hospital Discharge:
Implications for Risk Assessment and Management. Behav. Sci. La, 24, 731-746. Sudak H., Maxim K., Carpenter M.E. (2008), Suicide and Stigma: A Review of the Literature and Personal Reflections.
Academic Psychiatry, 32(2), 136-142. Tidemalm D., Långström N., Lichtenstein, P., Runeson, B. (2008) Risk of Suicide after suicide attempt according to
coexisting psychiatric disorder: Swedish cohort study with long-term follow-up. BMJ, 337, a2205. Torrey, E.F. & Zdanowicz, M. (2001). Outpatient Commitment: What, Why, and For Whom? Psychiatric Services, 52(3),
337-341. U.S. Department of Health and Human Services. (n.d.) Healthy People 2010. Retrieved on June 11, 2011 from:
http://www.healthypeople.gov/2020/default.aspx. U.S. Department of Health and Human Services. (2001) National strategy for suicide prevention: Goals and objectives for
action. Public Health Service. Rockville; MD. Retrieved on July 19, 2011 from: http://store.samhsa.gov/shin/content//SMA01-3517/SMA01-3517.pdf.
U.S. Public Health Service. (1999). The Surgeon General’s Call to Action to Prevent Suicide. Washington, D.C. Wang A.G and Mortensen G. (2006). Core Features of Repeated Suicidal Behavior: A long-term follow-up after suicide
attempts in a low-incidence population. Soc Psychiatry Psychiatr Epidemiol, 41, 103-107. Wenzel A., Beck A.T. (2008) A cognitive model of suicidal behavior: Theory and Treatment. Applied and Preventive
Psychology, 12, 189-201. Wiklander M., Samuelsson M., Åsberg M. (2003) Shame Reaction after suicide attempt. Scan J Caring Science, 17, 293-
300.
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