Suicide is a major public health concern, accounting for 41,149 deaths in the United States in 2014 according to the Centers for Disease Control and Prevention.1 The World Health Organization estimated that approximately 800,000 deaths worldwide in 2014 were due to suicide,2 and across all age groups it is the tenth leading cause of death.3 Suicide can have a significant societal impact due to increased health care costs, years of life lost, loss of work productivity, and stress on families.2 In 2013, the estimated national cost of suicide in the United States exceeded $58.4 billion.2 Suicidal behavior, including ideation and attempts, is a preventable cause of death, so mitigation of the associated factors can have a significant impact on people reporting suicidal behavior as well as their loved ones and caregivers.
Severe mental illness increases the risk of suicide, and approximately 50% of those who die from suicide have previously been referred to psychiatric services.3 Major depressive disorder has an annual prevalence of 9.6%, and is the most common mental health disorder seen in primary care.4 Both psychiatric (eg, depression, schizophrenia, alcohol or substance use, posttraumatic stress disorder) and medical disorders (eg, traumatic brain injury, HIV, renal failure, asthma, and cancer) are associated with an increased risk of suicide.5 To better understand the neurobiology of suicidality, there is a growing body of knowledge that supports the stress diathesis model, which states that stress can activate a disposition toward psychological vulnerability, leading to the risk of suicidality.6 Recently, suicide research has focused on the role of biological markers for suicide because early identification can be significant in the prevention and treatment of suicide.7
Policies related to deinstitutionalization and shorter hospital stays can have a significant impact on the risk of suicide, because now there is greater emphasis on community-based care.8 However, these policies may have adverse consequences due to the lack of resources for outpatient services, coordinated care, and screening tools to predict the future risk of suicide after discharge from the hospital. Emergency department physicians frequently see patients with suicidal behaviors or depression who can be challenging to manage.5 Risk stratification for suicidal behaviors is thus critically important in clinical decision-making.
Although several factors are associated with an increased risk of suicide, the specific risk factors in psychiatric patients for completing suicide are not well delineated. Identifying patients who are at risk for suicide after hospital discharge is particularly crucial. This review focuses on factors that are associated with an increased risk of suicide after hospital discharge in patients with psychiatric illnesses, and it aims to provide a deeper understanding of the risk factors for suicidal behaviors during the transition of care. It identifies high-risk factors that can be essential in efforts to prevent some suicide attempts. The categories found to be associated with higher post-discharge risk of suicide are demographic factors, social factors, factors related to the clinical setting and care, clinical factors, and service delivery. No clear criteria emerged from this literature review that providers can follow to assess the risk of post-hospital discharge suicide; thus, additional studies are needed to develop an evidence-based set of guidelines clinicians can use to prevent post-hospital discharge suicide.
In April 2018, we systematically searched two electronic databases (PubMed and Scopus) for relevant publications with the following search terms: “suicide” AND “hospital” OR “emergency department” AND “discharge”. Only original research and human studies were selected for this review. Two independent reviewers manually searched the references and relevant articles for inclusion. Search results from the two databases were imported into Endnote X7 (Thomson Reuters, Toronto, ON) to remove any duplicates. Two independent reviewers screened the titles and abstracts (when available), followed by full-text screening of all 743 articles included to select original studies that investigated the risk factors for post-hospital discharge suicides. In case of disagreement, a consensus was reached by discussion between the reviewers or guidance from a senior reviewer (SN). All of the studies investigating risk factors associated with increased risk of suicidal behavior during transition of care were included, without any restrictions on language, country, publication year, age, gender, or ethnicity of the patients. Abstract-only publications, conference papers without original data, review articles, theses, posters, book chapters, editorials, letters, and commentaries were excluded.
An electronic search using PubMed and Scopus databases retrieved 743 suitable studies. After a stringent screening process, we included 37 suitable articles reporting factors associated with suicidal behavior in the present review.
Suicide Rates During Transition of Care
Geddes et al.9 investigated suicide rates in the 12 months after discharge from psychiatric inpatient care in Scotland from the years 1968 to 1992. They reported that 1,212 male patients committed suicide in 198,059 person-years at risk, and 1,099 female patients committed suicide in 228,993 person-years at risk, representing an overall standardized mortality ratio of 27 in men and 40 in women.9 Valenstein et al.,10 in their retrospective cohort of 887,859 US veterans who were receiving treatment for depression between 1999 and 2004, found that the overall suicide rate was 114:100,000 person-years.
Demographic characteristics including age, gender, marital status, race, and employment status have been assessed for their role in the occurrence of post-hospital discharge suicides. The association of age with risk of post-discharge suicides was investigated in several studies, with mixed results. Age older than 60 years has been associated with a higher risk of post-hospital discharge suicide in different age cohorts.11–13 Similar results were reported for patients in the Veterans Affairs health care system.10 Another study found an increased risk of suicide among people age 45 to 64 years.8 This increased risk of post-hospital discharge suicide among older populations has been related to a plethora of biopsychosocial factors, including debilitating conditions such as dementia or Alzheimer's disease, loneliness, poor social networks, and dependence on others in routine life.9–13 However, the evidence regarding relationships between the post-discharge increase in suicide risk and the biopsychosocial factors is inconclusive in older populations.9 Moreover, the present literature search did not yield any studies reporting a possible association between teenage years and risk of suicide.
Gender is an important variable on the risk of post-hospital discharge suicide attempts. A study in Taiwan found that women were at a higher risk for suicidal behaviors,12 and this finding is consistent with other studies that investigated the risk of suicidal behaviors in adolescents and adults after hospital discharge.14,15 However, most studies reported that men are more likely to complete suicide after discharge from a facility.3,9,11,16,17 Interestingly, women were more likely to complete suicide within 1 month after hospital discharge compared to a period of more than 1 month.12,18
Studies published to date suggest that ethnicity, employment status, and relationship status are independent risk factors for an increased risk of suicide after discharge from the hospital.3,14,18–21 White patients are at an increased risk of suicide after discharge. In addition, unemployment and being single are independent risk factors for suicide after discharge. In a study of US veterans, the risk of reattempting suicide was highest among those who were divorced or separated, followed by married and then never-married participants.22 For instance, living in a rural setting increased the risk of suicide by 20% whereas homelessness was associated with a lower risk.23 In another study of adolescents in the United States, youth living in the Midwest had a significant risk whereas living in the Northeast was associated with a lower risk.21 Higher levels of education were also associated with higher risk of suicide.18
Social issues including interpersonal support, social network, and financial status play an important role in suicide attempts. Patients at a higher risk of post-hospital discharge suicide lack a secure social network and effective communication skills, and struggle with stressful interpersonal relationship; these issues can enhance the feeling of isolation even after receiving treatment.14,24 When these patients were made aware of these risk factors and provided with social support in the form of systematic contacts with caregivers, it allowed them to feel connected and effectively cope during suicidal crises.21,24 Brent et al.25 found an association between parental financial concerns, unemployment, and post-discharge suicide attempts. Employment is not only a source of financial independence but also provides opportunities for social networking, support, and prestige that can enhance self-worth.26 One study proposed that the idea of “loss” is represented well by these factors, which can lead to both suicidal ideation and actual attempts.25
Service Delivery Factors
Factors related to clinical care are critical in assessing the risk of post-hospital discharge suicide; for example, patients discharged from hospitals and emergency rooms were at a higher risk in some studies.12,17,19 Notably, adolescents were also at higher risk if they were treated in an adult facility.19 Length of hospital stay can also contribute to the risk of suicide, with shorter duration being associated with greater risk. Hospital stays lasting fewer than 14 days were connected with the greatest risk,27 with a period of less than 1 week being the most critical window.12 Another significant risk factor is time since discharge, with the highest risk being closer to discharge. A number of studies have investigated time since discharge as a risk factor for suicide. One found that the highest risk was on the first day after discharge,20 and high risk was also reported for the first few days after discharge.28 Higher risk was also found for the first week after discharge,9 the first 28 to 30 days after discharge,12,17,29 and 3 months after discharge.10,13 First hospitalization, a history of multiple hospitalizations, frequent visits to emergency departments, and involuntary admissions also posed a high risk for post-hospital discharge suicide.18,30–32
Health insurance plays a role in the medical and psychiatric care of patients in current health care systems. Levine et al.19 found that individuals with private insurance were less likely to be discharged to psychiatric, rehabilitation, or chronic care facilities compared to patients covered by Medicaid. Patient-initiated discharges and discharges against medical advice were found to significantly increase the risk of post-discharge suicide.2,15,33,34 This risk was higher in the first 2 weeks after patient-initiated discharge or discharge against medical advice, and personality disorders were frequently diagnosed in these patients.20 Moreover, discharge against medical advice can affect follow-up care. Meehan et al.20 reported that patients initiating their own discharge against medical advice report a higher likelihood of suicide attempts. This increased suicidal behavior was linked to several factors such as a primary diagnosis of personality disorder, a history of violence, drug misuse, lack of continuing community care, missing their last follow-up appointment, severe symptoms at their final contact, and being out of contact with services at the time of suicide.20 Several studies suggested that lack of follow-up services can lead to a higher risk of suicide.10,26,32 Interestingly, published findings also suggested that most patients had been in recent contact with their mental health providers before attempting suicide,15 pointing toward a possibility of less-intense care, which is an underrecognized future risk of suicide, and the importance of other related factors.
Several studies suggested that people with affective disorders were at a higher risk of attempting suicide immediately after discharge compared to those with other disorders.18,19,23,25,28,34–37 However, it was found that clinical improvement with antidepressants decreased this risk.36 In people with bipolar disorder, the risk of suicide attempt was 20-fold higher than in the general population.38 A temporal pattern of suicide risk was found in bipolar disorder, in which the risk was dependent primarily on the phase of illness.38 In the bipolar depressive phase, the risk was highest initially but declined significantly after discharge; in the manic phase, the risk was lower initially and relatively stable after resolution of the stage itself.38 Although the incidence of suicide attempts was highest in mixed episodes, post-discharge suicide risk was not highest among patients hospitalized for a mixed episode.38 Lastly, it appears that patients being treated for the depressive phase were at the highest immediate risk (within 3 months) for suicide.39 Schizophrenia spectrum disorders, personality disorders,4,35 adjustment disorders,35 and substance use disorders24,26 can also increase the risk of suicide. In two studies,23,40 anxiety disorders were considered to potentiate the risk of suicide after discharge.
Although it is evident that post-discharge suicide risk is higher in the weeks and months following discharge from inpatient psychiatric services compared to the general population, predicting who is at a higher risk is exceptionally challenging.34 Those with a history of suicide attempts and ideation before hospitalization, especially those with more than one suicide attempt in the past or a history of self-injurious behavior, were at increased risk for completing a suicide attempt post-discharge.34 A history of suicidal ideation and attempts appeared to be prevalent at both admission and discharge; thus, comprehensive discharge planning is necessary to decrease these incidents.3 Furthermore, it was found that people who make statements that reflect an acceptance of suicide were more likely to attempt it within 2 months of discharge. Hence, one's positive attitude toward acceptability of suicide and lack of condemnation towards it can also have a significant impact on behavior.41
The most common methods of suicide in these studies are hanging, firearm, and self-poisoning;3,19,20,41 psychotropic medications were more likely to be used in these suicides. Lastly, nonadherence to medication was a significant risk factor that correlated with increased suicide attempts after hospitalizations, especially in patients younger than age 35 years.20,42
This review article provides insights into the factors associated with the risk of suicide after hospital discharge. Demographic characteristics, social issues, factors related to service delivery, and clinical factors have been connected with a higher risk of discharge. Older age and adolescence, male gender, white race, unemployment, being single, and higher educational status have been associated with an increased risk of suicide after discharge. Adolescents are more likely to engage in risk-taking and impulsive behaviors, resulting in premature deaths by suicide, accidents, and homicide.41 However, there are mixed results regarding the links between a certain age group and the risk of post-discharge suicide. One study reported that older individuals had a higher percentage of nonfatal self-harm incidents compared to all other age groups.5 Female patients are more likely to seek help during psychological and emotional distress, and this may be the reason for the comparatively higher risk of suicide completion in men. It is possible that men are hesitant to seek help due to the stigma of not appearing “strong.”43 However, higher rates among women during the first month after discharge may be due to premature discharge and inadequately treated mental illness.
Social factors such as chronic stress, stressful interpersonal relationships, parent-child conflict, and unemployment can create potentially stressful situations after discharge.25,37 Adequate social support during the transition from hospital care may have a protective role in dealing with life stressors. The lack of social support coupled with a shorter length of hospital stay and premature transition are potentiating factors for suicide during the transition of care. Hoyer et al.37 also found that post-discharge suicide risk increased with short duration of hospital stays, possibly because patients are discharged before they reach their stable baseline. Patients who completed suicide within the first week post-discharge were found to have severe psychopathology, more functional impairment, and a lesser overall response to hospitalization, especially considering the higher risk during the initial days after discharge.18
Hospital characteristics and type of insurance are important risk factors related to suicide completion. Public insurance (ie, Medicaid) provides greater access to inpatient psychiatric care and residential-level care.14 In terms of hospital type, university hospitals have more access to specialized health care, psychosocial services, and more effective community outreach programs.14 People living in the vicinity of cities and towns with these resources are fortunate in that they are able to seek consultation more frequently in an outpatient setting. Because the number of outpatient visits is related to suicide during the first month after health care contact, these patients are less likely to commit suicide. The correlation between reduced care and suicide underscores the importance of continuing care long after the crisis is over. Stress management and ongoing suicide risk assessment after hospital discharge are clinically important, considering the lack of association between suicide completion and situations precipitating the crisis.
A root cause analysis of unplanned discharges suggests that they are not accompanied by follow-up care; in this situation, patients may receive inadequate treatment and there may be minimal involvement of outpatient providers or family members in formalizing follow-up care. In some instances, patients left the unit in distress and anger with the care team.28 Patient-initiated discharge and discharges against medical advice also lack these critical components of care. This highlights the importance of formulating a comprehensive and well-coordinated after-care plan at the time of discharge. The first hospitalization, a history of multiple hospitalizations, frequent visits to emergency departments, and involuntary admissions are all factors suggestive of greater clinical severity. Affective disorder, especially the depressive phase, is related with a greater risk of suicide that nonetheless tends to improve with treatment.36 Most antidepressants need at least 2 to 4 weeks to exert an effect in patients, again highlighting the role of comprehensive discharge planning and effective safety planning at the time of discharge. Mental health providers need to identify these risk factors and develop well-grounded post-discharge plans to meet the needs of their patients during the transition of care.
Strengths and Limitations
This review article aims to provide a concise resource for clinicians to ascertain risk factors associated with suicidal behavior during transition of care. However, this review was designed as a narrative literature review, and strict criteria according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and quality assessment of eligible studies common in systematic reviews were not applied here. Therefore, the results of this review should be interpreted with caution.
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- Exbrayat S, Coudrot C, Gourdon X, et al. Effect of telephone follow-up on repeated suicide attempt in patients discharged from an emergency psychiatry department: a controlled study. BMC Psychiatry. 2017;17(1):96. doi:. doi:10.1186/s12888-017-1258-6 [CrossRef]28320345
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