Psychiatric Patients at Highest Suicide Risk Following Hospital Discharge

Patients recently discharged from psychiatric hospitals for the treatment of depressive disorders and bipolar disorder may be at the greatest short-term risk of suicide, particularly if they appear to have had little contact with the health care system for months before their hospitalization, according to a study published in JAMA Psychiatry.

The study was led by Mark Olfson, M.D., M.P.H., a professor of psychiatry at Columbia University Medical Center.

“Inpatient psychiatrists experience strong financial pressures to keep inpatient stays brief,” Olfson told Psychiatric News. “These pressures complicate already difficult challenges in determining which inpatients are at greatest short-term risk of suicide following hospital discharge.”

For the study, Olfson and colleagues used Medicaid claims data from January 1, 2001, to December 31, 2007, to examine suicide risk during the first 90 days after inpatient hospital discharge for adults aged 18 to 64 with a diagnosis of a mental disorder (depressive disorder, bipolar disorder, schizophrenia, substance use disorder, and other mental disorders). This risk was then compared with the short-term suicide risk of inpatients with a diagnosis that was not a mental disorder. A total of 370 deaths by suicide occurred during the study period.

Based on an analysis of more than 1.8 million people—including 770,642 adults with mental disorders—the authors found that short-term suicide rates in the groups of adults with depressive disorder (235.1 per 100,000 person-years), bipolar disorder (216.0 per 100,000 person-years), schizophrenia (168.3 per 100,000 person-years), substance use disorder (116.5 per 100,000 person-years), and other mental disorders (160.4 per 100,000 person-years) were higher than the rates in the inpatients who were not diagnosed with a mental disorder (11.6 per 100,000 person-years) or the U.S. general population (14.2 per 100,000 person-years).

Additional analyses showed that the 90-day rate of suicide was nearly twice as high for men as women in the group with any mental disorder. Psychiatric inpatients who did not receive any outpatient health care in the six months prior to hospitalization were also found to be at increased short-term risk of suicide.

“These patterns suggest that complex psychopathologic diagnoses with prominent depressive features, especially among adults who are not strongly tied into a system of care, may pose a particularly high risk,” Olfson and colleagues wrote.

Olfson told Psychiatric News that the findings emphasize the importance of connecting patients being discharged from the hospital to outpatient psychiatric care.

“Psychiatric patients should not be considered cured at the time of discharge. They are still ill, many of their symptoms continue, treatment is ongoing, and their need for care remains. ... It is, therefore, very important to carefully plan and initiate referrals for aftercare,” Merete Nordentoft, D.M.Sc., and colleagues at the Mental Health Centre Copenhagen (MHCC) in Demark wrote in a related editorial appearing in JAMA Psychiatry. “When patients are most vulnerable, we need to provide responsible care, despite budget restrictions.”

The study was funded by the Agency for Healthcare Research and Quality and by the New York State Psychiatric Institute. ■

An abstract of “Short-Term Suicide Risk Af-ter Psychiatric Hospital Discharge” can be accessed here. The related editorial, “Post-discharge Suicides: Nightmare and Dis-grace,” is available here.