Systematic Suicide Risk Assessment for Patients With Schizophrenia: A National Population-Based Study

This national follow-up study was based on data from Danish health care registries. The Danish health care system provides tax-paid health care to the country’s 5.5 million residents, all of whom have free access to hospital care and general practitioners. Patients with schizophrenia are exclusively admitted to public psychiatric hospitals. The entire population is covered by a large number of administrative and medical registries, which are used for monitoring and regulating all central aspects of the public sector, including the health care system. Through the use of a civil registry number, which is unique to each Danish citizen, unambiguous linkages between the population-based registers can be made.

Data on suicide risk assessment were available for 7,107 of the 9,745 included patients (73%). Overall, 79% of all patients with available data had been systematically assessed for suicide risk in the study period (Table 1). The proportion of patients being assessed for suicide risk increased steadily during the period between 2005 and 2009, from 72% (CI=69%−71%) in 2005, when the national monitoring started, to 89% (CI=87%−89%) in 2009 (p<.001) (Figure 1).

Males were less likely than females to be assessed for suicide risk (adjusted OR [AOR]=.78, CI=.68–.90), and persons over age 30 were less likely than those younger than 30 to receive a suicide risk assessment, because the trend for odds decreased with increasing age (ages 30–39, AOR=.86; ages 40–49, AOR=.86; ages 50–59, AOR=.76; and ages ≥60, AOR=.60).

Patients who abused alcohol or drugs (except abusers of benzodiazepines and central nervous system–stimulating drugs) were less likely to receive a suicide risk assessment than those who did not abuse alcohol or drugs (AORs ranged from .67 for abuse of other street drugs to .96 for abuse of alcohol). However, only abuse of other street drugs was statistically significantly different compared with no abuse (p=.04). Persons with a GAF score ≥30 were more likely to receive a suicide risk assessment than those with a GAF score of <30 (AORs ranged from 1.57 for a GAF score of 40–49 to 1.64 for a GAF score of 30–39). Receiving psychoeducation during hospitalization was also associated with increased odds of suicide risk assessment before hospital discharge (AOR=1.89) (Table 1).

Incident (new) schizophrenia cases constituted 19% (N=1,821) of the study population. Sixty-four percent (N=1,162) were assessed for suicide risk, and approximately 23% (N=414) had missing information on suicide risk assessment (Table 2). Patients who received a psychopathology assessment performed by a medical specialist (AOR=1.47, p=.07) or by interview test (AOR=1.57, p=.02) were more likely to receive a suicide risk assessment than patients who did not receive such assessments, but the difference was not statistically significant for assessments performed by medical specialists. Patients newly diagnosed as having schizophrenia who received a cognitive test were also more likely than patients who did not to receive a suicide risk assessment (AOR=1.56, p=.01).

We found no substantial differences in the analyses based on the original and the imputed data sets, respectively (data not shown).

Approximately 1% (N=64) of the patients died by suicide, and 8% (N=427) attempted suicide in the first 12 months after hospital discharge. A majority of suicides were completed by men (74%, N=47), whereas women constituted a majority of suicide attempts (74%, N=316). Among those who died by suicide, 66% (N=42) had received a documented suicide risk assessment, whereas no assessment had been made or data were missing for the other patients. Approximately 10% (N=6) of the completed suicides occurred in the first week after discharge, and of those 50% (N=3) had received a systematic risk assessment. With regard to persons who had attempted suicide, 73% (N=313) had received a suicide risk assessment before discharge. Approximately 9% (N=37) of the attempted suicides occurred within the first week of discharge, and of these 70% (N=26) of the patients had been assessed for suicide risk before discharge (data not shown).

The use of systematic suicide risk assessment among patients with schizophrenia at the time of discharge from a psychiatric ward increased in Denmark between 2005 and 2009, following recommendations in national clinical guidelines and monitoring in a national clinical registry. Still, a substantial proportion of patients, including patients who were expected to be at the highest risk of suicide (specifically, males and patients with new schizophrenia diagnoses), did not appear to receive a systematic assessment before hospital discharge despite clear recommendations in the clinical guidelines (19,20).

Implementation of clinical treatment guidelines is complex, and several studies have concluded that adherence to guidelines in psychiatric care is often low (21–23). Differences have been found between psychiatry and somatic specialties in the attitudes and knowledge about guidelines and evidence-based medical practices, some of which are explained by lack of a tradition of following clinical guidelines in psychiatric treatment (24). Bauer (25) reviewed the adherence to mental health clinical guidelines and found adequate adherence in only 27% of the observational studies and 67% of the controlled trials. Six barriers to adherence to recommended clinical guidelines in health care in general have been identified: lack of awareness of existing guidelines, lack of familiarity with guidelines, lack of agreement with guidelines, lack of self-efficacy in providing certain treatments, low outcome expectancy from treatment, and inertia concerning previous practice (26). These barriers may also explain the lack of adherence to guidelines in psychiatric care. In addition, Azocar and colleagues (22) found that among clinicians failing to follow clinical guidelines for treatment of major depression, 96% stated they were too busy to read the guidelines and 38% reported they did not want to be told how to practice by managed care organizations.

Despite the recommendations for the use of systematic suicide risk assessment, the predictive value of the risk assessment is modest due to the high prevalence of the assessment of risk factors and the low rate of suicidal behavior (27). Systematic suicide risk assessment should therefore be used with caution to guide clinicians and patients but should not stand alone. Attention to overall improvements in the care provided both before and after discharge is therefore warranted.

The strengths of this study include the availability of a national population-based schizophrenia registry, prospective collection of data on suicide risk assessment from all Danish psychiatric wards, and the availability of detailed data on a wide range of covariates. Moreover, the unique civil registry number system enabled complete follow-up by linkage to other registries. Study limitations included missing information on suicide risk assessment and to a varying degree the patient- and treatment-related covariates. In addition, the dichotomous suicide risk assessment (yes-no) registration in the DNIP was a crude variable that may not have captured whether the assessment was carefully conducted in all situations. Finally, using a hospital discharge registry to identify suicide attempters enabled us to capture only events that led to hospitalization and the diagnoses of suicide attempters by the health care professionals treating them.

The use of systematic suicide risk assessment before discharge from Danish psychiatric wards has increased within recent years, since the introduction of a nationwide quality-of-care initiative. Additional efforts appear warranted in order to ensure that all patients receive systematic suicide risk assessment before being discharged and that appropriate measures are taken to lower the risk of suicidal behavior.

The authors report no competing interests.