Suicide In Psychiatric Inpatients Research Articles

The Integrated Motivational-Volitional Model of Suicidal Behavior

Suicide is a major public health concern accounting for 800 000 deaths globally each year. Although there have been many advances in understanding suicide risk in recent decades, our ability to predict suicide is no better now than it was 50 years ago. There are many potential explanations for this lack of progress, but the absence, until recently, of comprehensive theoretical models that predict the emergence of suicidal ideation distinct from the transition between suicidal ideation and suicide attempts/suicide is key to this lack of progress. The current article presents the integrated motivational–volitional (IMV) model of suicidal behaviour, one such theoretical model. We propose that defeat and entrapment drive the emergence of suicidal ideation and that a group of factors, entitled volitional moderators (VMs), govern the transition from suicidal ideation to suicidal behaviour. According to the IMV model, VMs include access to the means of suicide, exposure to suicidal behaviour, capability for suicide (fearlessness about death and increased physical pain tolerance), planning, impulsivity, mental imagery and past suicidal behaviour. In this article, we describe the theoretical origins of the IMV model, the key premises underpinning the model, empirical tests of the model and future research directions.

Predictors of Psychiatric Inpatient Suicide

To study the incidence and risk factors of psychiatric inpatient suicide within a national cohort representing all psychiatric hospital admissions. This national prospective register-based study followed all psychiatric hospital admissions in Denmark from the date of patient admission until patient discharge or inpatient suicide over a 10-year study period from 1997 through 2006. By using survival analysis techniques, this study was the first to take the inpatient time at risk into account in the estimation of the suicide rate and the predictors of suicide among hospital-admitted psychiatric patients. Among 126,382 psychiatric inpatients aged 14 years or older, 279 suicides occurred. The risk of inpatient suicide was high: 860 suicides per 100,000 inpatient years. Of those individuals who completed suicide, 50% died within 18 days of admission. The inpatient suicide rate significantly decreased, about 6% each year (HR = 0.94; 95% CI, 0.90-0.99), over this 10-year period. Several significant predictors of suicide were found, including the following: Patients with a bachelor's degree had a significantly higher hazard ratio (HR) of suicide compared with those with a primary school education (HR = 0.41; 95% CI, 0.29-0.60) or those with vocational training (HR = 0.54; 95% CI, 0.39-0.77). Having a personality disorder as a secondary diagnosis (all psychiatric diagnoses were made according to ICD-10) raised the risk of suicide (HR = 1.60; 95% CI, 1.01-2.53), as did having recent contact (within the last year) with a private psychologist (HR = 1.85; 95% CI, 1.05-3.28). Recent suicide attempt before admission to the hospital was associated with the highest risk of inpatient suicide (HR = 4.99; 95% CI, 3.57-6.96). This study demonstrated a high risk of psychiatric inpatient suicide in Denmark of 860 per 100,000 inpatient years and also revealed several significant predictors of psychiatric inpatient suicide. Furthermore, the inpatient suicide rate decreased from 1997 through 2006 in Denmark.

Managing the risk of suicide in acute psychiatric inpatients: A clinical judgement analysis of staff predictions of imminent suicide risk

Background: Predicting suicide risk in psychiatric in-patients in order to inform risk management decisions is compromised by the poor predictive validity of the available models.Aims: This study explored the factors influencing judgements regarding suicide risk in psychiatrists and nurses working in acute psychiatric in-patient units in Scotland.Method: Clinical judgement analysis. Information used by 12 psychiatrists and 52 nurses to make judgements about suicide risk were analysed over 130 hypothetical cases. Correlations and linear regression analysis were used to examine judgement consistency and information use.Results: There was agreement between clinicians on the relative but not absolute degree of risk of each patient case. Consistency of judgments was low, particularly amongst nurses. All clinicians rated those with more previous suicide attempts, men, those with shorter admission times, and those who were less compliant and not improving clinically as at greater risk of suicide.Conclusions: Clinicians use cues that have been associated with suicide in traditional predictive models based on epidemiological studies and short term factors that may be particularly relevant to acute psychiatric settings. The inconsistencies observed can be interpreted to cast doubt on the validity of predictions of risk for imminent suicide and the role of such predictions in the assessment process.Declaration of interest: None.

Suicide in current psychiatric in-patients: a case-control study The National Confidential Inquiry into Suicide and Homicide

Few controlled studies have investigated factors associated with suicide in current in-patients. We aimed to identify psychosocial, behavioural and clinical risk factors, including variations in care, for in-patient suicide. We conducted a national population-based case-control study of people who died by suicide between 1 April 1999 and 31 December 2000 while in psychiatric in-patient care in England. Cases were 222 adult mental health in-patients who died by suicide matched on date of death with 222 living controls. Nearly a quarter of suicides took place within the first week of admission; most of these died on the ward or after absconding. After the first week, however, most suicides occurred away from the ward, the majority of patients having left the ward with staff agreement. Previous deliberate self-harm, recent adverse life events, symptoms of mental illness at last contact with staff and a co-morbid psychiatric disorder were associated with increased risk for suicide. Being off the ward without staff agreement was a particularly strong predictor. Those patients who were detained for compulsory treatment were less likely to die by suicide. Independent predictors of in-patient suicide were male sex, a primary diagnosis of affective disorder and a history of self-harm. Being unemployed or on long-term sick leave appeared to be independently protective. Prevention of in-patient suicide should emphasize adequate treatment of affective disorder, vigilance in the first week of admission and regular risk assessments during recovery and prior to granting leave. Use of compulsory treatment may reduce risk.

Suicide in psychiatric in-patients in England, 1997 to 2003

Psychiatric in-patients are at particularly high risk of suicide but few studies have investigated trends in in-patient suicide over time. We conducted a prospective study of all patients admitted to National Health Service (NHS) in-patient psychiatric care in England (1997-2003). The study was carried out as part of the National Confidential Inquiry into Suicide. The main outcome measure was death by suicide. Suicide rates were determined using Hospital Episode Statistics (HES) as the denominator. Between the first 2 years of the study (1997 and 1998) and the last 2 years of the study (2002 and 2003) the annual number of in-patient deaths from suicide fell from 187 to 156 (a 17% reduction). The rate of in-patient suicide fell by between 9% and 28% depending on which denominator was used. This fall was observed for both males and females, and was most marked for those aged 15-44 years. Reductions were also observed for the three most common methods of death (hanging, jumping, poisoning), but the trend for hanging did not reach statistical significance. Although the number of post-discharge suicides fell, the risk of post-discharge suicide (using admissions as a denominator) may have increased by as much as 10% during the study period. The rate of suicide among psychiatric in-patients appears to have fallen. The fall may reflect falling general population rates, changes in in-patient case mix, service improvements, or a transfer of risk to the post-discharge period. Services need to be aware of the importance of providing high quality aftercare following discharge from hospital.

Re: Psychiatric Diagnosis and Suicide

The paper of Bertolote, Fleischmann, De Leo, and Wasserman (Crisis, 2004, 25:147–155) is a potentially influential review of psychiatric diagnosis and suicide, as it purports to present data that diminish the importance of the treatment of mental disorders, particularly depression, in suicide prevention. However, it has a number of flaws that should be acknowledged before necessarily accepting their conclusions. From the methodological point of view one can not simply add the numbers of suicides from widely varying studies to arrive at valid data in terms of general population or psychiatric inpatient suicides. For example, subjects taken from a series of persons who have jumped from bridges or who have died by suicide in underground railways are hardly likely to be representative of a broader general sample of suicides in the community. Furthermore, the three largest studies from the UK, Denmark, and Israel, which comprised over 75% of what the authors referred to as general population suicides, were actually suicides of persons who had had psychiatric contact. Indeed, not only were many of those persons psychiatric inpatients at the time of death, but the authors of the UK study reported that their large sample comprised less than 25% of the total UK suicides. It is probable that psychotic illnesses were more likely to be represented in such psychiatric samples, therefore biasing the results. Bertolote et al. have also confined their analysis to traditional psychological autopsy-type data and have ignored more recently available population attributablerisk research, such as that from Denmark (Qin, Agerbo, & Mortensen, 2003), which allows for the relative importance of various contributing factors to be estimated. That research demonstrated clearly that psychiatric illness sufficiently severe to lead to hospitalization is of overwhelming importance in suicide at the broad population level, and that psychosocial issues such as being on a pension, having a low income, or being unemployed are of far lesser importance. The authors have also stated that they were interested in looking at the geographical origin of the published research, but those two studies from non-Western countries comprised only 216 subjects, or 1.4% of the total, and, therefore, one must be particularly cautious in considering that the overall results would apply to other nonWestern countries. The authors have suggested that strategies should not be “focusing exclusively on the identification and treatment of depression,” but I am not aware of any broad international programs that have been so focused, although there have been regional programs that have done so and that show promise in suicide reduction. The authors have also not distinguished the approaches to suicide prevention that may be appropriate in one country as opposed to another. The focus on mental illness, and in particular depression, is probably the most appropriate approach in developed countries, as many of the psychosocial stressors that may be more amenable to social manipulation have already been addressed. However, for countries with very high suicide rates, clearly addressing psychosocial factors will hold more promise in terms of reducing suicide. This has been illustrated in a model that integrates the role of biological and psychosocial factors contributing to suicide (Goldney, 2003), where it was postulated that there is a base rate of suicide caused by intractable, biologically based, mental disorders, albeit with a contribution from psycho-social stressors, but the relative importance of biological factors diminishes as suicide rates increase. There is a need to delineate more clearly the relative importance of psychiatric illness and psychosocial factors, not only in individual countries, but also in specific regions within countries where there may be unusually high suicide rates. The lumping together of disparate

A case-control study of 92 cases of in-patient suicides

Background A significant number of patients committed suicide while receiving in-patient treatment in psychiatric hospitals. Most previous studies on psychiatric in-patient suicides were conducted in the West. This study aimed to describe the characteristics and identify risk factors of suicides occurring during psychiatric in-patient care in Hong Kong. Method The case record data of suicide cases (Coroner's verdicts of suicides and undetermined deaths) from all public psychiatric hospitals in the entire region within a 3 years' period ( N = 93) were compared with matched controls. Results In-patient suicide rate was 269/100,000 admissions. Majority had schizophrenia. Suicide usually occurred after the first month of admission, during leave, and by jump from heights. There were little case-control differences in treatment received. Multiple conditional logistic regression found 5 risk factors: previous history of deliberate self-harm (OR = 4.60, 95% CI = 1.57–13.5); admitted because of suicidal behaviour (OR = 3.92, 95% CI = 1.3–11.9); depressive symptoms at time of suicide (OR = 8.53, 95% CI = 1.4–52); away without leave at anytime during index admission (OR = 17, 95% CI = 1.76–163); and extrapyramidal side effects/akathisia at time of suicide (OR = 10.8, 95% CI = 1.75–66.7). Limitations Retrospective case record review depended on non-standardized and variable quality of case notes entry. Matching for hospitals in this study would make the comparison between hospitals impossible. Although this is the second largest case-control study of psychiatric in-patient suicide, the estimated power suggested subtle risk factors would be missed. Conclusion Majority of in-patient suicides occurred at a time of perceived low risk. A high sensitivity to the risk of suicide and vigorous treatment of depressive symptoms were indicated. The care processes during the index admission could bear strong influences on the risk of in-patient suicides.

Social fragmentation, severe mental illness and suicide.

Geographic patterns of suicide are associated with area levels of social fragmentation. It is unknown whether this reflects higher levels of severe mental illness in socially fragmented areas. Data on psychiatric inpatient admissions and suicides amongst people aged 15-64 living in the City of Bristol [1991-1992] were postcode matched to the city's 34 electoral wards. Ecological associations of psychiatric admission (used as a 'proxy' measure of prevalence of severe mental illness) and suicide rates with levels of social fragmentation were investigated using negative binomial regression models. Psychiatric hospital admission rates were higher in areas with high levels of socioeconomic deprivation than in areas with high levels of social fragmentation. In contrast, associations with suicide were stronger in relation to social fragmentation than socioeconomic deprivation. Association of suicide with social fragmentation was only moderately attenuated in models controlling for psychiatric admission rate and socio-economic deprivation, RR 1.23 (95 % C. I. 1.09-1.38) per quartile increase in social fragmentation, compared to 1.29 (95% C. I. 1.16-1.44) before adjustment. The association between social fragmentation and suicide is not explained by socioeconomic deprivation or the prevalence of severe mental illness within socially fragmented areas as measured by psychiatric admission rate.

Barometric pressure, emergency psychiatric visits, and violent acts.

Associations between human behaviour and psychiatric decompensation and weather variables have been inconsistent. We studied the association of certain weather variables (specifically, humidity, wind speed, and barometric pressure) with emergent psychiatric presentations, psychiatric admissions, incidence of violent crimes, and suicides in a metropolitan area. We performed a retrospective study for the year 1999 in a mid-sized city. We included all documented emergent psychiatric visits to the city's psychiatric emergency room. We obtained violence data from the city police department and suicide data from the country medical examiner. The data suggest that total numbers of acts of violence and emergency psychiatry visits are significantly associated with low barometric pressure. Psychiatric inpatient admissions and suicides are not associated with any of the weather variables investigated. While alternate conclusions can be drawn, we propose that the data support the interpretation that low barometric pressure is associated with an increase in impulsive behaviours. Additional investigation is warranted.

Comparison of psychiatric inpatient suicides with suicides completed in the surrounding community

We compared main characteristics of 58 (22 male and 36 female) psychiatric inpatients that committed suicide in the psychiatric hospital with all 1261 suicides (956 male and 305 female) that occurred outside hospitals in the same health district of Slovenia, all these in the period between 1985 and 1993. The independent t -test and cross-tabulation were used to compare the two groups on age, sex, marital status and suicide method profile. It appeared that female suicide is much more frequent in the psychiatric inpatients' group than in others. Only male psychiatric inpatients' suicides are younger than other suicide victims. Psychiatric inpatients use methods like jumping from high places and drowning more often than do others, which goes in line with the availability of methods of suicide. Apparently, the studied hospital has some wards on the third floor and majority of acute wards are located by the river. However, psychiatric inpatients do not differ from other suicide victims on marital status. Higher suicide rates in men compared with women in the population, but not in psychiatric inpatients, could be explained by the presence of so-called atypical, clinically unrecognized depression in the male population.

The development of suicide rates in the Bezirkskrankenhaus Bayreuth 1976 - (including) 2000

Newer publications about psychiatric in-patient suicide discuss the so-called "increase hypothesis" of suicide of mentally ill in-patients controversially. In our study of in-patient suicides of the Bezirkskrankenhaus Bayreuth, a state mental hospital for adult psychiatry, the number of suicides and suicide rate over 25 years 1979 - 2000 did not show any increase. During the last 4 - 5 years we observe a trend toward a decrease.

Multimethod Assessment of Suicidality in Adolescent Psychiatric Inpatients: Preliminary Results

To examine agreement among multiple assessments of adolescent suicidal ideation and suicidal behavior for adolescent psychiatric inpatients, including pencil/paper checklists; structured and unstructured interviews; and adolescent, clinician, and parent reports, and to provide suggestions for the accurate and reliable assessment of suicidality in adolescence. Participants included 153 adolescent psychiatric inpatients (54 boys, 99 girls) between the ages of 12 and 17 years. Measurement of suicidal ideation and behavior included common assessment instruments and standard clinical practices, including the Suicidal Ideation Questionnaire, NIMH Diagnostic Interview Schedule for Children, clinician interview, and parent report (Behavior Assessment Scale for Children). Results revealed significantly different rates of suicidality across each instrument and poor to moderate agreement between similar measures of adolescent suicidal ideation and suicidal behavior. Agreement between measures was generally best for boys, for older adolescents, and for assessments relying on a single informant. Reporters were most likely to agree on the presence of suicidality for more severely suicidal adolescents; this finding suggests that agreement in itself may be a useful marker for adolescent suicide. Results of this preliminary study supported the use of multiple measurement approaches when examining adolescent suicidality, particularly those that rely on clinician judgment and adolescents' own reports. Implications for future research and for clinical practice are also discussed.

Dependency and suicidality in psychiatric inpatients

One hundred fifty-two psychiatric inpatients (91 women and 61 men) completed widely used objective (i.e., self-report) and projective measures of interpersonal dependency; scores on these measures were compared to two indices of suicidality derived from patients' chart records (i.e., number of past suicide attempts and physician judgments of suicidality at admission). High objective dependency scores were associated with high suicidality scores in women and men, even when level of depression was controlled for statistically. Projective dependency scores were unrelated to both suicidality indices. © 2000 John Wiley & Sons, Inc. J Clin Psychol 56: 463–473, 2000.

Dependency and suicidality in psychiatric inpatients.

One hundred fifty-two psychiatric inpatients (91 women and 61 men) completed widely used objective (i.e., self-report) and projective measures of interpersonal dependency; scores on these measures were compared to two indices of suicidality derived from patients' chart records (i.e., number of past suicide attempts and physician judgments of suicidality at admission). High objective dependency scores were associated with high suicidality scores in women and men, even when level of depression was controlled for statistically. Projective dependency scores were unrelated to both suicidality indices.

Suicide in psychiatric hospital in-patients. Risk factors and their predictive power.

Psychiatric hospital in-patients are known to be at high risk of suicide, yet there is little reliable knowledge of risk factors or their predictive power. To identify risk factors for suicide in psychiatric hospital in-patients and to evaluate their predictive power in detecting people at risk of suicide. Using a case-control design, 112 people who committed suicide while in-patients in psychiatric hospitals were compared with 112 randomly selected controls. Univariate analysis and multivariate analyses were used to estimate odds ratios and adjusted likelihood ratios. The rate of suicide in psychiatric in-patients was 13.7 (95% CI 11.7-16.1) per 10,000 admissions. There were five predictive factors with likelihood ratios > 2, following adjustment: planned suicide attempt, 4.1; actual suicide attempt, 4.9; recent bereavement, 4.0; presence of delusions, 2.3; chronic mental illness, 2.2; and family history of suicide, 4.6. On this basis, only two of the patients who committed suicide had a predicted risk of suicide above 5%. Although several factors were identified that were strongly associated with suicide, their clinical utility is limited by low sensitivity and specificity, combined with the rarity of suicide, even in this high-risk group.

Suicide in psychiatric inpatients in Ireland

AbstractObjectives:To establish suicide rates of psychiatric inpatients in Ireland and the characteristics, demographic, social and medical, of the patients involved.Method:Clinical, post mortem and inquest data on all such deaths from 1983-1992 were examined. Suicide rates were calculated using ‘person year method’.Results:The suicide rate for short stay inpatients (stay less than one year) was 319/100,000, and 118/100,000 for long stay patients. The average duration of illness at time of suicide was 10 years. A fourfold increase in suicide rate of inpatients over the century was associated with a similar increase in the suicide rate in the general population. Thirty five per cent of suicides were aged 25-34 years. The risk of suicide was higher the shorter the time interval after admission. Three quarters of suicide deaths in registered inpatients occurred away from hospital grounds.Conclusions:Social factors which contribute to an increase in the suicide rate in the general population are relevant to the increase in hospital inpatient suicides. More effective and comprehensive services to meet the needs of those with severe mental illness, particularly young adults, are essential. The results emphasise the importance of managing inpatients in a safe, secure environment. The person year method is appropriate for monitoring changes in suicide rates.

Depression, Hopelessness, and Self‐Esteem: Accounting for Suicidality in Adolescent Psychiatric Inpatients

The present study was designed to examine depression, hopelessness, and self-esteem as related to suicidal behavior in three groups of depressed adolescent psychiatric inpatients. Depressed adolescents who had never attempted suicide were compared to depressed adolescents who had attempted suicide once and to depressed adolescents who had attempted suicide on several different occasions. Results showed that suicidal adolescents experienced significantly greater depression and hopelessness than did the nonsuicidal adolescents. However, all three groups of depressed adolescents reported similar low levels of self-esteem. Measures of depression and hopelessness were useful in classifying the adolescents based on their suicidal behavior. Results suggest that the treatment of suicidal adolescents could benefit from strategies that focus on reducing feelings of depression and hopelessness.

Suicide among psychiatric in-patients with schizophrenia in an Australian mental hospital.

Psychiatric in-patient suicides are associated with schizophrenia. In this paper, 62 suicides in patients with schizophrenia, over a 21-year period in a large psychiatric hospital in Melbourne, Australia, were examined. The characteristics, including demographic and clinical data, for the suicides were compared with a comparison group of 22 'alive' in-patients with schizophrenia. Suicide among in-patients with schizophrenia was associated with previous deliberate self-harm, a greater number of episodes of previous deliberate self-harm, pre-admission and intra-admission suicidal thoughts, intra-admission suicidal attempts, fluctuating suicidal ideation, longer length of stay, a greater number of ward transfers, and prescription of a greater number of neuroleptics and antidepressants. Over 40% of suicides occurred after absconding from hospital and a similar number during periods of approved leave. Violent methods (including jumping in front of trains, trams and road traffic, jumping off buildings, hanging and drowning) were most frequently used. It is concluded that psychiatric units should be developed away from readily available methods of suicide. In-patients at high risk should be observed carefully to avoid absconding and suicide. Suicide risk should be examined carefully in patients prior to approving leave, particularly if they have fluctuating suicidal ideation.

Suicide of psychiatric inpatients 1970-1993 in baden- württemberg (germany)

The well-known fact of suicides of psychiatric inpatients during psychiatric hospital treatment is discussed according to national and international suicide data. In our Baden-Württemberg (Germany) Psychiatric Inpatient Suicide Study an increase in suicide and suicide rates from 1970 to 1993 can be shown with an mostly impressive increase in the 1970s and a plateau formation in the 1980s and constant figures in the 1990s. The group of 585 suicides (59% men, 41% women) is composed of: 26% primarily depressives, 53% schizophrenics (ICD-9); where the following features were notable presuicidal syndrome with depressive mood (68%). insight into illness (63%). feelings of suffering (64%), failure (57%), hopelessness (54%) and helplessness (54%).

Psychiatric in-patient suicide rates: a 21-year study.

Psychiatric in-patient suicides were traced from the hospital death register for the 21-year period 1973 to 1993. Suicide rates for each of the 21 years were calculated and an overall rate of 3.68 per 1,000 admissions was found. Suicide rates for the period after 1987 were significantly lower than for the period before 1987. However, there was a significant upward trend during the last three years of the study period. The role of the new Mental Health Act (introduced in 1987) on reducing the suicide rate and the effects of the amalgamation of three hospitals on increasing the rate are discussed.