Next Article in Journal
Research and Application of an Air Quality Early Warning System Based on a Modified Least Squares Support Vector Machine and a Cloud Model
Next Article in Special Issue
Suicide Behaviors in Adult Inpatients with Mental Disorders in Beijing, China
Previous Article in Journal
Risk Factors for Chronic Diseases and Multimorbidity in a Primary Care Context of Central Argentina: A Web-Based Interactive and Cross-Sectional Study
Previous Article in Special Issue
A Novel Therapy for People Who Attempt Suicide and Why We Need New Models of Suicide
Open AccessReview

Risk Estimates and Risk Factors Related to Psychiatric Inpatient Suicide—An Overview

1
Danish Research Institute for Suicide Prevention, Copenhagen Mental Health center, 2900 Hellerup, Denmark
2
Department of Mental Health, Bloomberg Johns Hopkins School of Public Health, Baltimore, MD 21205, USA
3
Institute of Regional Health Research, University of Southern Denmark, 5000 Odense, Denmark
*
Author to whom correspondence should be addressed.
Academic Editors: Rory O’Connor and Gwendolyn Portzky
Int. J. Environ. Res. Public Health 2017, 14(3), 253; https://doi.org/10.3390/ijerph14030253
Received: 25 January 2017 / Accepted: 22 February 2017 / Published: 2 March 2017
(This article belongs to the Special Issue From Understanding Suicide Risk to Preventing Suicide)

Abstract

People with mental illness have an increased risk of suicide. The aim of this paper is to provide an overview of suicide risk estimates among psychiatric inpatients based on the body of evidence found in scientific peer-reviewed literature; primarily focusing on the relative risks, rates, time trends, and socio-demographic and clinical risk factors of suicide in psychiatric inpatients. Psychiatric inpatients have a very high risk of suicide relative to the background population, but it remains challenging for clinicians to identify those patients that are most likely to die from suicide during admission. Most studies are based on low power, thus compromising quality and generalisability. The few studies with sufficient statistical power mainly identified non-modifiable risk predictors such as male gender, diagnosis, or recent deliberate self-harm. Also, the predictive value of these predictors is low. It would be of great benefit if future studies would be based on large samples while focusing on modifiable predictors over the course of an admission, such as hopelessness, depressive symptoms, and family/social situations. This would improve our chances of developing better risk assessment tools.
Keywords: suicide; psychiatric inpatients; epidemiology; review suicide; psychiatric inpatients; epidemiology; review

1. Introduction

People with mental illness have an elevated risk of dying prematurely from both natural and unnatural causes [1,2], and their average life span is found to be about 15–20 years shorter than that of the general population [3]. The excess mortality in psychiatric patients is partly explained by an increased risk of suicide [4,5,6]. Large national register-based studies have shown that about 44% of all people who die by suicide have been admitted to a psychiatric hospital [7,8]. In the long term, approximately 4%–5% of people admitted to a psychiatric hospital will die by suicide [6]. Psychological autopsy studies have estimated that up to 90% of people who died by suicide met the criteria for a psychiatric disorder [9,10]. Interviews have found that up to two-thirds of people after self-harm indicated that they had attended mental health care prior to the incident [11,12,13]; thus, the association between mental illness and suicidal behaviour is well-established.
The risk of suicide in psychiatric patients varies over time, and an excessive risk of suicide has been found in patients who are currently admitted or who have been recently discharged from a psychiatric hospital [14,15,16,17]. Although suicides among hospitalised psychiatric patients are rare, it is considered to be a public health problem [18]. Given that many are admitted due to suicidal predispositions, it is thus common practice to evaluate patients’ suicide risk. While suicidal ideation in inpatients may in some cases be inevitable, a hospital stay is still considered protective against suicide, and when, despite precautions, suicide deaths occur, it causes immense distress for both family members and ward staff [19,20].
This paper aims to provide an overview of the scientific literature addressing the risk of suicide associated with a psychiatric inpatient stay. We will be addressing the relative risk, rates, time trends, and socio-demographic and clinical risk factors of suicide in psychiatric inpatients and conclude with a discussion and implication of the available evidence based peer-reviewed literature.

2. Relative Risk

Approximately 5% of all suicides occur among currently admitted psychiatric patients [21,22,23,24]. Although 5% may sound low, the relative risk of dying by suicide whilst being admitted to psychiatric hospital is alarmingly high compared with the general population. For example, psychiatric inpatients with an affective disorder have an almost 150 times higher suicide risk than people who have never been hospitalised; the excess risk is found across psychiatric diagnoses [21]. Overall, psychiatric inpatients have a rate of 147 suicides per 100,000 patient-years [14], which is almost 13 times higher than the annual global age-standardized suicide rate of 11.4 per 100,000, provided by the World Health Organization (WHO) [25]. While acknowledging that not all people with mental disorders receive treatment, a recent study found that the risk of suicide varies according to the level of mental health care received; people admitted as psychiatric inpatients within the last year had a 44-fold higher risk of suicide than the general population, whereas those receiving outpatient care or psychiatric medication had an 8- or 6-fold higher risk, respectively [15]. It would probably be wrong to conclude that the treatment causally increases risk of suicide; presumably, effective treatment would decrease the risk of suicide compared to a scenario in which that person did not receive treatment. The association is likely explained through selection; people with frequent psychiatric contact might be at higher risk of dying by suicide because their psychiatric symptoms are more severe than those of patients with less frequent contact. As such, the results could indicate that the psychiatric treatment system successfully identifies people who require treatment, implying that people who have been psychiatrically hospitalized constitute an important group for suicide preventive measures.
A large national cohort study from Denmark noted a decreasing suicide rate among psychiatric inpatients towards the end of the last century but at a significantly slower pace compared to the rate of people who had not been admitted to psychiatric hospital [21], thus suggesting that the excess mortality by suicide among psychiatric inpatients had grown over time. However, an update of this study is needed to determine the current trends of suicide among psychiatric inpatients versus the general population.

3. Psychiatric Inpatient Suicide: When, Where and How

The risk of suicide is highest in recently admitted patients, and a large nationwide study found that the median admission time of those who died by suicide was 18 days (interquartile range (IQR): 6, 57) [16], which is in agreement with others studies. As many as one quarter of inpatient suicides take place within the first week of admission [16,26,27,28,29]. Two of the largest studies showed that the majority of patients did not die at the hospital ward; Danish and English studies reported respectively that 58% [16] and 74% [27] of suicides occurred outside the ward while the patients were admitted. Comparable figures are reported from Switzerland [30], Austria [31], and Canada [32]. Furthermore, the English study listed that 32% died on the ward, 39% were on agreed leave, and 29% had left the ward without notifying the clinical staff [27]. Those who died by suicide during the first week of admission predominantly died either at the ward or off the ward while absconding. On the other hand, patients who died by suicide after more than a week of admission were more likely to have been on agreed leave. A recent large scale observational study compared patients admitted to hospitals or wards with or without locked doors and found no difference in the risk of completed suicide [33]. Several studies [16,27,31,32] have noted that the most frequently used methods among inpatients are hanging (especially if it happens at the ward) or jumping from a height or in front of a vehicle (especially among absconders) [23], while suicides by overdose and drowning are less frequent.

4. Prevalence, Rates and Time Change of Inpatient Suicide

Cohort studies have found that suicide occurs in between 0.14%–0.32% of all psychiatric inpatients, while suicides are found to occur with a frequency of 0.08%–0.19% per admission [16,34,35,36,37].
Table 1 lists inpatient suicide rates with respect to admissions, patients, and inpatient person-years, and when comparing rates it is obviously important that the denominator is the same. Most studies have reported rates of inpatient suicide per number of admissions or patients, probably because this type of data is easier to collect through routine clinical data. Inpatient rates have been estimated to be between 54 and 404 suicides per 100,000 admissions [31,34,36,37,38,39,40,41,42,43] and between 127 and 332 suicides per 100,000 patients [35,37,43,44,45]. Expectedly, rates calculated per inpatient are higher than rates calculated per admission, as one patient can have more than one admission. Only few studies have reported rates calculated per inpatient person-years, i.e., using time at risk (as an inpatient) for the rate estimation. Estimating rates per inpatient person-years is often viewed as more informative as it allows for a comparison with rates of other groups, such as the background population. In this manner, the relatively high rates in psychiatric inpatients can be visualised more clearly. A study from 1980 revealed a suicide rate of 450 per 100,000 inpatient years, thus using time at risk (inpatient person-years) for the suicide rate estimation [34]. A recent English study measured suicide rates according to inpatient person-days and noted a rate of 1.02 per 100,000 total bed days (corresponding to 373 per 100,000 inpatient person-years) [46], and a study from Taiwan showed rates of 686 and 295 per 100,000 inpatient person-years, respectively, for the periods 1985–1995 and 1998–2008. A Danish study reported an even higher rate of 860 per 100,000 inpatient person-years [16]. The severity of inpatient suicides becomes more worrisome when comparing this rate with that of the background population, which was 11.4 per 100,000 person-year [25].
Table 1 illustrates the variability in inpatient suicide rates. This might be related to differences between the included studies with relation to: (1) the psychiatric population admitted to hospital; (2) the level of provided care (e.g. staff per patient); (3) period effects; or (4) level of ‘suicide’ safety measures implemented in the hospitals (some wards might have implemented better restrictive measures for preventing access to suicidal means). A recent meta-analysis by Walsh et al. [14]. on the rates of psychiatric inpatient suicide found that inpatient suicide rates were higher in recent studies compared with studies based on data prior to 1980 [14]. The authors suggested that the observed increase in inpatient suicide rates could be explained by the de-institutionalization processes, leading to a change in the diagnostic profile of patients admitted to hospital. For instance, patients with less severe mental illnesses are nowadays to a larger extent treated in outpatient settings, implying a higher proportion of severely ill patients with high risks of suicide among inpatients. Consequently, a higher suicide rate would be expected among inpatients. While Walsh et al. [14] noted in their meta-analyses that previous studies found lower suicide rates than more recent studies, only few studies have actually addressed the period effects of inpatient suicide rates. Large cohort studies from England, Israel, and Denmark have reported a significant decreasing trend in inpatient suicide rates from the late 1990s into the new millennium [49,50,51]. The English study found that the decrease was highest in the youngest age group (15–44 years) and among patients with schizophrenia, whereas the Danish study noted that the decrease was most pronounced among female patients. Both these studies were conducted during periods of de-institutionalization, and both studies discussed whether these processes, such as shorter inpatient stays, might have resulted in a transfer of the suicide risk from the inpatient period to the discharge period. Both studies found that the suicide rate had changed among those patients recently discharged. In England, the rate of post-discharge suicide rose from 1.39 per 1000 discharges in 1997/98 to 1.66 per 1000 discharges in 2007/08 [50], whereas, in Denmark, the post-discharge suicide rate was found to have decreased [52].

5. Predictors of Inpatient Suicide

Several studies have examined the predictors of inpatient suicide in those admitted to a psychiatric hospital. The main findings are summarized in the following two tables; Table 2 lists studies that have examined the predictors for psychiatric inpatient suicide with a control patient population, while Table 3 lists the main findings from these studies.
Table 2 reveals that most studies were based on relatively small samples and lists only few cases of inpatient suicides. Furthermore, most studies used a case-control design and logistic regression analyses. Some few studies were based on patients with a certain diagnosis only [30,35,38,53], or the analysis was conducted separately for different diagnoses [44] (see comments in Table 2). Only one study included a national sample of patients [16]. In other words, Table 2 shows the variation in study designs and power. Table 3 discloses that our knowledge on the socio-demographic and clinical predictors for inpatient suicide, despite many years of research, remains uncertain and limited. For instance, most original studies, as well as the meta-analyses, reported non-significant findings with respect to gender. However, the two largest studies [16,27] (as measured by most cases of suicide) both find that the male sex was associated with a more than twofold higher risk of suicide compared with female inpatients. The results regarding age also point in different directions; some studies found support for a higher risk among younger patients, while others showed that the risk increased with increasing age, and yet others reported no significant impact of age. In the background population, male gender and increasing age are generally associated with a higher risk of suicide in Western countries [59]. Interestingly, a few studies found that higher education, high income, and being employed (as opposed to unemployed) were associated with an increased risk of suicide. Generally, higher education, high income, and being employed have been associated with lower mortality rates, including suicide [59,60]. It has been discussed whether the reverse associations between these social-economic variables and suicide in psychiatric populations might be explained by well-functioning people who suddenly find themselves in a stressful situation when facing psychiatric illness because they: (1) are afraid of losing income, employment, or the ability to use their education; (2) might feel more stigmatized by their social surroundings; or (3) have a greater insight into the course of the mental illness. The last is a commonly held view for which the existing literature presents conflicting evidence as to whether greater insight increases or decreases the risk of suicidal behaviour [44,61,62,63]. The most established predictors of inpatient suicide appear to be depressive symptoms during admission, a diagnosis of an affective disorder or a schizophrenia spectrum disorder, and a history of deliberate self-harm. Evidence for these predictors is supported by a systematic review and meta-analyses by Large et al. [58] (see Table 3). In addition to the predictors listed in Table 3, the meta-analyses identified a family history of suicide or mental illness, high levels of hopelessness, feelings of worthlessness or guilt, prescribed antidepressants, and longer length of hospitalisation as predictors of suicide. No link to suicide was found for social or relationship problems, physical illness, prior criminality/violence, suicidal ideation at admission, agitation or anxiety, delusional ideas, hallucinations, or prescribed antipsychotic drugs. Finally, some studies have suggested that the side effects of psychopharmacological medicine might increase the risk of inpatient suicide [36,40]. However, one of the largest case-control studies [41] of 112 suicides did not find a significant association between medication and suicide. Insights into illness [44] and absconding from hospital [27] have also been associated with risk of suicide.
Also, the comparison across studies is not uncomplicated; several of the studies were based on older psychiatric populations who had received different treatments than more recent populations. Secondly, some studies examined predictors that had not been described in sufficient detail, leaving the reader unable to interpret the findings. For instance, one study examined educational level, broken homes, and living and vocational situations as predictors, but the authors did not describe how these variables were constructed [53]. Several other studies [27,36,40,41,45,57] based on clinical data have only vaguely described how depressive symptoms, hallucinations, or delusions were derived. These are not unitarily defined and could, therefore, be measured differently with respect to the frequency, severity, and type of delusions, making comparisons between studies less reliable. Another issue pertains to the fact that most studies were carried out in high-income countries, and the results might thus not be generalised to other parts of the world.
The identification of predictors of suicide is challenged by the fact that suicide is a rare event, and, when studied in a relatively small population of psychiatric inpatients, it is even more difficult to secure sufficiently robust risk estimates. It is appropriate to mention some of the limitations that apply to several of the presented studies. Numerous studies were based on a few observations of suicide deaths (see Table 2); only a few original studies included more than 100 inpatient suicide deaths [16,27,41]. Consequently, many of the presented estimates were based on univariate associations with no adjustment for confounding variables and wide confidence intervals. On the other hand, some of the studies that presented multivariate associations did not provide the results from the univariate analysis, leaving the reader unable to evaluate whether adjustment lead to changes in the estimates [37,53] (see Table 3). In addition, most studies used a case-control design, in which the ability to generalise the results to the full population of psychiatric inpatients may be compromised because the selection of controls might be biased. For example, some studies matched cases to the next patient admitted to the same hospital or ward [30,39,54], increasing the probability of a comparison to patients frequently hospitalised, potentially representative of patients with a more chronic disease profile.

6. Clinical Implication

The aim of this review was to describe the rates and risk factors of inpatient suicides. We have compared inpatients to the background population, examined differences in risk among psychiatric inpatients, and assessed risk predictors for inpatient suicide. Overall, and not surprisingly, the findings from various scientific studies tell us that patients admitted to psychiatric hospitals have an extremely high risk of suicide while being in treatment with compared to the background population. However, what also stands out is that between 0.14%–0.32% of all psychiatric inpatients die by suicide while admitted. In other words, psychiatric inpatients constitute a high-risk group with respect to suicide. However, within this group, it can be difficult to identify the few patients who will die by suicide due to the low prevalence of suicide.
In terms of clinical implications, clinicians should always be alert regarding the suicide risks of psychiatric patients, and this should, ideally, be assessed and addressed. A conversation focusing on suicidal risk with the patient should be carried out in a calm setting where trust and confidence between patient and clinician is paramount. Obviously, the conversation should be performed in a flexible and caring manner. Above we presented the established predictors of inpatient suicides; however, whether a risk assessment based on these risk predictors is valid has been debated [64,65]. It is difficult to predict suicide because it is a rare event, and, as acknowledged by others, the rate of false positives is high; most psychiatric patients will never display suicidal behaviour despite presenting one or several risk predictors [66]. Studies examining the predictive value of risk assessment based on known high-risk predictors have shown a lack of certainty in the prediction. An algorithm for the exact calculation of suicide risk will probably never be achieved, especially since suicidal ideation and symptoms of depression fluctuate, while impulsivity also plays a major role, implying a constant change in suicidal risk. Nevertheless, checklists or risk screening might provide guidance to which items ought to be covered in a conversation focusing on risk assessment.

7. Conclusions

In sum, psychiatric inpatients have a high risk of suicide, but it is still a challenge for clinicians to identify those patients that are most likely to die by suicide during admission. This review concluded that the literature on inpatient suicide in most cases was based on studies with low power (few suicide cases), compromising the quality and generalisability of the study results. The few studies with some power mainly identified non-modifiable risk predictors, such as male gender, diagnosis, or recent deliberate self-harm. It would be of great benefit if future studies of inpatient suicide were based on large samples sizes and focused on modifiable predictors that can change over the course of admission, such as hopelessness, depressive symptoms, and family/social situations. This could improve our chances for developing better risk assessment tools. In order to prevent inpatient suicides, a continuous focus on the risk of suicide is necessary, ideally in dialogue with the inpatient. This focus ought to go hand in hand with aims of improving care for people with mental illness, through effective communication between wards, with the aim of improving risk management in inpatient settings, as well as reducing accessibility to the means and possibilities for absconding.

Author Contributions

Trine Madsen, Annette Erlangsen, and Merete Nordentoft planned design and content of this overview, Trine Madsen drafted the manuscript, and all co-authors contributed to and agreed on the final version.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Tidemalm, D.; Waern, M.; Stefansson, C.G.; Elofsson, S.; Runeson, B. Excess mortality in persons with severe mental disorder in Sweden: A cohort study of 12,103 individuals with and without contact with psychiatric services. Clin. Pract. Epidemiol. Ment. Health 2008, 4, 23. [Google Scholar] [PubMed]
  2. Nordentoft, M.; Wahlbeck, K.; Hällgren, J.; Westman, J.; Ösby, U.; Alinaghizadeh, H.; Gissler, M.; Laursen, T.M. Excess Mortality, Causes of Death and Life Expectancy in 270,770 Patients with Recent Onset of Mental Disorders in Denmark, Finland and Sweden. PLoS ONE 2013, 8, e55176. [Google Scholar] [CrossRef] [PubMed]
  3. Wahlbeck, K.; Westman, J.; Nordentoft, M.; Gissler, M.; Laursen, T.M. Outcomes of Nordic mental health systems: Life expectancy of patients with mental disorders. Br. J. Psychiatry 2011, 199, 453–458. [Google Scholar] [CrossRef] [PubMed]
  4. Bostwick, J.M.; Pankratz, V.S. Affective disorders and suicide risk: A reexamination. Am. J. Psychiatry 2000, 157, 1925–1932. [Google Scholar] [CrossRef] [PubMed]
  5. Palmer, B.A.; Pankratz, V.S.; Bostwick, J.M. The lifetime risk of suicide in schizophrenia: A reexamination. Arch. Gen. Psychiatry 2005, 62, 247–253. [Google Scholar] [CrossRef] [PubMed]
  6. Nordentoft, M.; Mortensen, P.B.; Pedersen, C.B. Absolute risk of suicide following first hospital contact with mental disorder. Arch. Gen. Psychiatry 2011, 68, 1058–1064. [Google Scholar] [CrossRef] [PubMed]
  7. Mortensen, P.B.; Agerbo, E.; Erikson, T.; Qin, P.; Westergaard-Nielsen, N. Psychiatric illness and risk factors for suicide in Denmark. Lancet 2000, 355, 9–12. [Google Scholar] [CrossRef]
  8. Qin, P.; Agerbo, E.; Mortensen, P.B. Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: A national register-based study of all suicides in Denmark, 1981–1997. Am. J. Psychiatry 2003, 160, 765–772. [Google Scholar] [CrossRef] [PubMed]
  9. Isometsa, E.T. Psychological autopsy studies—A review. Eur. Psychiatry 2001, 16, 379–385. [Google Scholar] [CrossRef]
  10. Cavanagh, J.T.O.; Carson, A.J.; Sharpe, M.; Lawrie, S.M. Psychological autopsy studies of suicide: A systematic review. Psychol. Med. 2003, 33, 395–405. [Google Scholar] [CrossRef] [PubMed]
  11. Owens, D.; Wood, C.; Greenwood, D.C.; Hughes, T.; Dennis, M. Mortality and suicide after non-fatal self-poisoning: 16-year outcome study. Br. J. Psychiatry 2005, 187, 470–475. [Google Scholar] [CrossRef] [PubMed]
  12. Cooper, J.; Kapur, N.; Webb, R.; Lawlor, M.; Guthrie, E.; Mackway-Jones, K.; Appleby, L. Suicide after deliberate self-harm: A 4-year cohort study. Am. J. Psychiatry 2005, 162, 297–303. [Google Scholar] [CrossRef] [PubMed]
  13. Suokas, J.; Suominen, K.; Isometsa, E.; Ostamo, A.; Lonnqvist, J. Long-term risk factors for suicide mortality after attempted suicide—Findings of a 14-year follow-up study. Acta Psychiatr. Scand. 2001, 104, 117–121. [Google Scholar] [CrossRef] [PubMed]
  14. Walsh, G.; Sara, G.; Ryan, C.J.; Large, M. Meta-analysis of suicide rates among psychiatric in-patients. Acta Psychiatr. Scand. 2015, 131, 174–184. [Google Scholar] [CrossRef] [PubMed]
  15. Hjorthøj, C.R.; Madsen, T.; Agerbo, E.; Nordentoft, M. Risk of suicide according to level of psychiatric treatment: A nationwide nested case-control study. Soc. Psychiatry Psychiatr. Epidemiol. 2014, 49, 1357–1365. [Google Scholar] [CrossRef] [PubMed]
  16. Madsen, T.; Agerbo, E.; Mortensen, P.B.; Nordentoft, M. Predictors of psychiatric inpatient suicide—A national prospective register-based study. J. Clin. Psychiatry 2012, 73, 144–151. [Google Scholar] [CrossRef] [PubMed]
  17. Olfson, M.; Wall, M.; Wang, S.; Crystal, S.; Liu, S.; Gerhard, T.; Blanco, C. Short-Term Suicide Risk Following Psychiatric Hospital Discharge. JAMA Psychiatry 2016, 73, 119–1126. [Google Scholar] [CrossRef] [PubMed]
  18. Foley, S.R.; Kelly, B.D. When a patient dies by suicide: Incidence, implications and coping strategies. Adv. Psychiatr. Treat. 2007, 13, 134–138. [Google Scholar] [CrossRef]
  19. Hodelet, N.; Hughson, M. What to do when a patient commits suicide. Psychiatr. Bull. 2001, 25, 43–45. [Google Scholar] [CrossRef]
  20. Hawton, K. Helping people bereaved by suicide. BMJ 2003, 327, 177–178. [Google Scholar] [CrossRef] [PubMed]
  21. Qin, P.; Nordentoft, M.; Hoyer, E.H.; Agerbo, E.; Laursen, T.M.; Mortensen, P.B. Trends in suicide risk associated with hospitalized psychiatric illness: A case-control study based on Danish longitudinal registers. J. Clin. Psychiatry 2006, 67, 1936–1941. [Google Scholar] [CrossRef] [PubMed]
  22. Appleby, L.; Shaw, J.; Sherrat, J.; Amos, T.; Robinson, J.; McDonnell, R. Safety First: Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness; Department of Health: London, UK, 2001. [Google Scholar]
  23. Hunt, I.M.; Windfuhr, K.; Swinson, N.; Shaw, J.; Appleby, L.; Kapur, N. Suicide amongst psychiatric in-patients who abscond from the ward: A national clinical survey. BMC Psychiatry 2010, 10, 14. [Google Scholar] [CrossRef] [PubMed]
  24. Blain, P.; Donaldson, L. The reporting of in-patient suicides: Identifying the problem. Public Health 1995, 109, 293–301. [Google Scholar] [CrossRef]
  25. World Health Organization. Preventing Suicide: A Global Imperative; World Health Organization: Geneva, Switzerland, 2014. [Google Scholar]
  26. Hunt, I.M.; Bickley, H.; Windfuhr, K.; Shaw, J.; Appleby, L.; Kapur, N. Suicide in recently admitted psychiatric in-patients: A case-control study. J. Affect. Disord. 2013, 144, 123–128. [Google Scholar] [CrossRef] [PubMed]
  27. Hunt, I.M.; Kapur, N.; Webb, R.; Robinson, J.; Burns, J.; Turnbull, P.; Shaw, J.; Appleby, L. Suicide in current psychiatric in-patients: A case-control study The National Confidential Inquiry into Suicide and Homicide. Psychol. Med. 2007, 37, 831–837. [Google Scholar] [CrossRef] [PubMed]
  28. Meehan, J.; Kapur, N.; Hunt, I.M.; Turnbull, P.; Robinson, J.; Bickley, H.; Parsons, R.; Flynn, S.; Burns, J.; Amos, T.; et al. Suicide in mental health in-patients and within 3 months of discharge. National clinical survey. Br. J. Psychiatry 2006, 188, 129–134. [Google Scholar] [CrossRef] [PubMed]
  29. Erlangsen, A.; Zarit, S.H.; Tu, X.; Conwell, Y. Suicide among Older Psychiatric Inpatients: An Evidence-Based Study of a High-Risk Group. Am. J. Geriatr Psychiatry 2006, 14, 734–741. [Google Scholar] [CrossRef] [PubMed]
  30. Modestin, J.; Zarro, I.; Waldvogel, D. A study of suicide in schizophrenic in-patients. Br. J. Psychiatry 1992, 160, 398–401. [Google Scholar] [CrossRef] [PubMed]
  31. Deisenhammer, E.A.; DeCol, C.; Honeder, M.; Hinterhuber, H.; Fleischhacker, W.W. In-patient suicide in psychiatric hospitals. Acta Psychiatr. Scand. 2000, 102, 290–294. [Google Scholar] [CrossRef] [PubMed]
  32. Proulx, F.; Lesage, A.D.; Grunberg, F. One hundred in-patient suicides. Br. J. Psychiatry 1997, 171, 247–250. [Google Scholar] [CrossRef] [PubMed]
  33. Huber, C.G.; Schneeberger, A.R.; Kowalinski, E.; Fröhlich, D.; von Felten, S.; Walter, M.; Zinkler, M.; Beine, K.; Heinz, A.; Borgwardt, S.; et al. Suicide risk and absconding in psychiatric hospitals with and without open door policies: A 15 year, observational study. Lancet Psychiatry 2016, 3, 842–849. [Google Scholar] [CrossRef]
  34. Gale, S.W.; Mesnikoff, A.; Fine, J.; Talbott, J.A. A study of suicide in state mental hospitals in New York City. Psychiatr. Q. 1980, 52, 201–213. [Google Scholar] [CrossRef] [PubMed]
  35. Krupinski, M.; Fischer, A.; Grohmann, R.; Engel, R.; Hollweg, M.; Moller, H.J. Risk factors for suicides of inpatients with depressive psychoses. Eur. Arch. Psychiatry Clin. Neurosci. 1998, 248, 141–147. [Google Scholar] [CrossRef] [PubMed]
  36. Neuner, T.; Schmid, R.; Wolfersdorf, M.; Spiessl, H. Predicting inpatient suicides and suicide attempts by using clinical routine data? Gen. Hosp. Psychiatry 2008, 30, 324–330. [Google Scholar] [CrossRef] [PubMed]
  37. Spiessl, H.; Hubner-Liebermann, B.; Cording, C. Suicidal behaviour of psychiatric in-patients. Acta Psychiatr. Scand. 2002, 106, 134–138. [Google Scholar] [CrossRef] [PubMed]
  38. Taiminen, T.J.; Kujari, H. Antipsychotic medication and suicide risk among schizophrenic and paranoid inpatients: A controlled retrospective study. Acta Psychiatr. Scand. 1994, 90, 247–251. [Google Scholar] [CrossRef] [PubMed]
  39. Read, D.A.; Thomas, C.S.; Mellsop, G.W. Suicide among psychiatric in-patients in the Wellington region. Aust. N. Z. J. Psychiatry 1993, 27, 392–398. [Google Scholar] [CrossRef] [PubMed]
  40. Dong, J.Y.; Ho, T.P.; Kan, C.K. A case-control study of 92 cases of in-patient suicides. J. Affect. Disord. 2005, 87, 91–99. [Google Scholar] [CrossRef] [PubMed]
  41. Powell, J.; Geddes, J.; Deeks, J.; Goldacre, M.; Hawton, K. Suicide in psychiatric hospital in-patients. Risk factors and their predictive power. Br. J. Psychiatry 2000, 176, 266–272. [Google Scholar] [CrossRef] [PubMed]
  42. Cheng, I.C.; Hu, F.C.; Tseng, M.C. Inpatient suicide in a general hospital. Gen. Hosp. Psychiatry 2009, 31, 110–115. [Google Scholar] [CrossRef] [PubMed]
  43. Lin, S.K.; Hung, T.M.; Liao, Y.T.; Lee, W.C.; Tsai, S.Y.; Chen, C.C.; Kuo, C.J. Protective and risk factors for inpatient suicides: A nested case-control study. Psychiatry Res. 2014, 217, 54–59. [Google Scholar] [CrossRef] [PubMed]
  44. Steblaj, A.; Tavcar, R.; Dernovsek, M.Z. Predictors of suicide in psychiatric hospital. Acta Psychiatr. Scand. 1999, 100, 383–388. [Google Scholar] [CrossRef] [PubMed]
  45. Li, J.; Ran, M.S.; Hao, Y.T.; Zhao, Z.H.; Guo, Y.B.; Su, J.H.; Lu, H.X. Inpatient suicide in a Chinese psychiatric hospital. Suicide Life Threat. Behav. 2008, 38, 449–455. [Google Scholar] [CrossRef] [PubMed]
  46. Kapur, N.; Hunt, I.M.; Webb, R.; Bickley, H.; Windfuhr, K.; Shaw, J.; Appleby, L. Suicide in psychiatric in-patients in England, 1997 to 2003. Psychol. Med. 2006, 36, 1485–1492. [Google Scholar] [CrossRef] [PubMed]
  47. Ajdacic-Gross, V.; Lauber, C.; Baumgartner, M.; Malti, T.; Rössler, W. In-patient suicide—A 13-year assessment. Acta Psychiatr Scand. 2009, 120, 71–75. [Google Scholar] [CrossRef] [PubMed]
  48. Jones, R.M.; Hales, H.; Butwell, M.; Ferriter, M.; Taylor, P.J. Suicide in high security hospital patients. Soc. Psychiatry Psychiatr. Epidemiol. 2011, 46, 723–731. [Google Scholar] [CrossRef] [PubMed]
  49. Levi, L.; Werbeloff, N.; Pugachova, I.; Yoffe, R.; Large, M.; Davidson, M.; Weiser, M. Has deinstitutionalization affected inpatient suicide? Psychiatric inpatient suicide rates between 1990 and 2013 in Israel. Schizophr. Res. 2016, 173, 75–78. [Google Scholar] [CrossRef] [PubMed]
  50. Kapur, N.; Hunt, I.M.; Windfuhr, K.; Rodway, C.; Webb, R.; Rahman, M.S.; Shaw, J.; Appleby, L. Psychiatric in-patient care and suicide in England, 1997 to 2008: A longitudinal study. Psychol. Med. 2013, 43, 61–71. [Google Scholar] [CrossRef] [PubMed]
  51. Madsen, T.; Agerbo, E.; Mortensen, P.B.; Nordentoft, M. Deliberate self-harm before psychiatric admission and risk of suicide: Survival in a Danish national cohort. Soc. Psychiatry Psychiatr. Epidemiol. 2013, 48, 1481–1489. [Google Scholar] [CrossRef] [PubMed]
  52. Madsen, T.; Nordentoft, M. Changes in inpatient and postdischarge suicide rates in a nationwide cohort of danish psychiatric inpatients, 1998–2005. J. Clin. Psychiatry 2013, 74, 1190–1194. [Google Scholar] [CrossRef] [PubMed]
  53. Modestin, J.; Kopp, W. Study on Suicide in Depressed Inpatients. J. Affect. Disord. 1988, 15, 157–162. [Google Scholar] [CrossRef]
  54. Roy, A.; Draper, R. Suicide among psychiatric hospital in-patients. Psychol. Med. 1995, 25, 199–202. [Google Scholar] [CrossRef] [PubMed]
  55. Shah, A.K.; Ganesvaran, T. Inpatient suicides in an Australian mental hospital. Aust. N. Z. J. Psychiatry 1997, 31, 291–298. [Google Scholar] [CrossRef] [PubMed]
  56. Sharma, V.; Persad, E.; Kueneman, K. A closer look at inpatient suicide. J. Affect. Disord. 1998, 47, 123–129. [Google Scholar] [CrossRef]
  57. King, E.A.; Baldwin, D.S.; Sinclair, J.M.; Campbell, M.J. The Wessex Recent In-Patient Suicide Study, 2. Case-control study of 59 in-patient suicides. Br. J. Psychiatry 2001, 178, 537–542. [Google Scholar] [CrossRef] [PubMed]
  58. Large, M.; Smith, G.; Sharma, S.; Nielssen, O.; Singh, S.P. Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients. Acta Psychiatr. Scand. 2011, 124, 18–19. [Google Scholar] [CrossRef] [PubMed]
  59. Hawton, K.; van Heeringen, K. Suicide. Lancet 2009, 373, 1372–1381. [Google Scholar] [CrossRef]
  60. Martikainen, P.; Blomgren, J.; Valkonen, T. Change in the total and independent effects of education and occupational social class on mortality: Analyses of all Finnish men and women in the period 1971–2000. J. Epidemiol. Community Health 2007, 61, 499–505. [Google Scholar] [CrossRef] [PubMed]
  61. Robinson, J.; Cotton, S.; Conus, P.; Schimmelmann, B.G.; McGorry, P.; Lambert, M. Prevalence and predictors of suicide attempt in an incidence cohort of 661 young people with first-episode psychosis. Aust. N. Z. J. Psychiatry 2009, 43, 149–157. [Google Scholar] [CrossRef] [PubMed]
  62. Barrett, E.A.; Sundet, K.; Faerden, A.; Agartz, I.; Bratlien, U.; Romm, K.L.; Mork, E.; Rossberg, J.I.; Steen, N.E.; Andreassen, O.A.; et al. Suicidality in first episode psychosis is associated with insight and negative beliefs about psychosis. Schizophr. Res. 2010, 123, 257–262. [Google Scholar] [CrossRef] [PubMed]
  63. Melle, I.; Ann Barrett, E. Insight and suicidal behavior in first-episode schizophrenia. Expert Rev. Neurother. 2012, 12, 353–359. [Google Scholar] [CrossRef] [PubMed]
  64. Large, M.; Ryan, C.; Nielssen, O. The validity and utility of risk assessment for inpatient suicide. Australas Psychiatry 2011, 19, 507–512. [Google Scholar] [PubMed]
  65. Large, M.M.; Ryan, C.J. Suicide risk categorisation of psychiatric inpatients: What it might mean and why it is of no use. Australas Psychiatry 2014, 22, 390–392. [Google Scholar] [CrossRef] [PubMed]
  66. Cassells, C.; Paterson, B.; Dowding, D.; Morrison, R. Long- and short-term risk factors in the prediction of inpatient suicide: Review of the literature. Crisis 2005, 26, 53–63. [Google Scholar] [CrossRef] [PubMed]
Table 1. Rates of inpatient suicide.
Table 1. Rates of inpatient suicide.
StudyStudy PeriodSuicides/100,000 AdmissionsSuicides/100,000 PatientsSuicides/100,000 Inpatient Years
Madsen et al. 2013 [16]1998–200578221860
Deisenhammer, 2000 [31]1987–1994132
Gale et al. 1980 [34]1975–1977188 450
Krupinski et al. 1998 [35]1981–1992 324
Neuner et al. 2008 [36]1995–2005101
Spiessl et al. 2002 [37]1989–199976142
Taiminen et al. 1994 [38]1967–1993404
Read et al. 1993 [39]1984–1989204
Dong et al. 2005 [40]1997–1999269
Powell et al. 2000 [41]1963–1992137
Cheng et al. 2009 [42]1995–2004162
Lin et al. 2014 [43]1998–200854127295
Lin et al. 2014 [43]1985–1995185332686
Steblaj et al. 1999 [44]1984–1993 243
Li et al. 2008 [45]1956–2005 133
Ajdacic-Gross et al. 2009 [47]1992–2004161
Jones et al. 2011 [48]1972–2000 162
Levi et al. 2016 [49]1990–201375 286
Kapur et al. 2006 [50]1997–2003 373 *
* Estimated/converted by the authors from 1.02 suicides per 100,000 bed days.
Table 2. Studies examining predictors of suicide among psychiatric inpatients.
Table 2. Studies examining predictors of suicide among psychiatric inpatients.
Author, YearSuicides/Non SuicidesDesignStatistical AnalysisComments
Madsen et al. 2012 [16]279/126,382CohortCox regressionNational sample
Hunt et al. 2007 [27]222/222Case-controlLogistic regression
Modestin et al. 1992 [30]53/53Case-controlLogistic regressionOnly patients with schizophrenia
Gale et al. 1980 [34]60/5105Cohortχ2-test
Krupinski et al. 1998 [35]33/3759CohortDiscriminant analysisPatients with affective psychosis
Neuner et al. 2008 [36]41/20,543CohortLogistic regression
Spiessl et al. 2002 [37]30/21,062CohortLogistic regression
Read et al. 1993 [39]27/86Case-controlLogistic regression
Taiminen et al. 1994 [38]28/28Case-controlLogistic regressionPatients with schizophrenia or paranoia
Powell et al. 2000 [41]112/112Case-controlLogistic regression
Lin et al. 2014 [43]43/162Case-controlLogistic regression
Steblaj et al. 1999 [44]79/79Case-controlLogistic regressionAnalyses carried out in diagnostic groups
Li et al. 2008 [45]64/64Case-controlLogistic regression
Ajdacic-Gross et al. 2009 [47]141/87,341CohortPoisson regression
Levi et al. 2016 [49]326/1304Case-controlLogistic regressionNational sample
Modestin & Kopp, 1988 [53]75/50Case-controlLogistic regression
Roy & Draper, 1995 [54]37/37Case-controlχ2-test
Shah & Ganesvaran, 1997 [55]60/60Case-controlχ2-test, t-test
Sharma et al. 1998 [56]44/44Case-controlχ2-test, ANOVA
King et al. 2001 [57]59/106Case-controlLogistic regression
Large et al. 2011 [58] Systematic reviewMeta-analysis Pooled odds ratios29 case-control studies
ANOVA: Analysis of variance.
Table 3. Outline of examined predictors for inpatient suicide. Reported risk estimates are all significant with a p-value below 0.05.
Table 3. Outline of examined predictors for inpatient suicide. Reported risk estimates are all significant with a p-value below 0.05.
Variable (Study)Risk Estimate Unadjusted Risk Estimate Adjusted CommentVariable (Study)Risk Estimate UnadjustedRisk Estimate Adjusted Comment
Male sex Age
Madsen et al. [16] 2.58
Hunt et al. [27]1.492.39 Madsen et al. [16] 1.18With increasing age
Gale et al. [34]NS Krupinski et al. [35]NS Comparing 10-year age groups
Krupinski et al. [35]NS Neuner et al. [36](+)NSHigher risk among younger patients.
Neuner et al. [36]NSNS Powell et al. [41]1.8 Risk for patients. <45 years of age
Read et al. [39]NS Lin et al. [43]NS
Powell et al. [41] NSNS Sharma et al. [56]NS Comparing mean age
Li et al. [45]NS Large et al. [58]NS With increasing age
Ajdacic-Gross et al. [47] 1.75
Levi et al. [49]1.851.92
Modestin & Kopp [53] (+)Male sex increased riskUnemployment
Shah & Ganesvaran [55]NS Madsen et al. [16]NSNS
Hunt et al. [27]0.210.17Compared to employed
Sharma et al. [56]NS Spiessl et al. [37] 5.21OR for part-time employed
Large et al. [58]NS Read et al. [39]NS
Educational level Dong et al. [40]NSNS
Madsen et al. [16]2.862.44For bachelor degree and up versus primary schoolPowell et al. [41]NS
Modestin et al. [30]NS Roy & Draper [54]NS
Sharma et al. [56]NS
Gale et al. [34]NS Males onlyLarge et al. [58]NS
Gale et al. [34](+) Females: Higher education⟹higher suicide riskLow income
Powell et al. [41]NSNSNo educational qualificationsMadsen et al. [16]NSNS
Modestin & Kopp [53] NS Modestin et al. [30](+) Low social class increased risk
Sharma et al. [56]NS Shah & Ganesvaran. [55](+) High social class increased risk
Marriage/cohabiting Living alone
Madsen et al. [16]0.61NSRisk for divorced, widowedMadsen et al. [16] 0.63NS
Hunt et al. [27]NSNS Hunt et al. [27] NSNS
Modestin et al. [30]NS Taiminen et al. [38]NSNS
Gale et al. [34]NS Dong et al. [40]NSNS
Krupinski et al. [35]NS Powell et al. [41]NS
Read et al. [39]4.1 Risk for single, divorced, widowedRoy & Draper [54]NS
Dong et al. [40]NSNS Sharma et al. [56]NS
Powell et al. [41]NS Large et al. [58]NS
Ajdacic-Gross et al. [47] 1.70 Outpatient treatment
Modestin & Kopp [53] NS Madsen et al. [16]NSNS
Roy & Draper [54]NS Neuner et al. [36] 4.11Supportive psychotherapy before admission
Sharma et al. [56]NS
Large et al. [58]NS Schizophrenia diagnosis
Affective diagnosis Madsen et al. [16]0.440.53Versus affective diagnosis
Madsen et al. [16]2.271.88Versus schizophrenia diagnosis Gale et al. [34](+) Increased risk if schizophrenia disorder
Hunt et al. [27]1.971.81Versus other diagnosesSpiessl et al. [37] 8.42
Gale et al. [34](+) Increased risk if affective disorderRead et al. [39]5.6
Powell et al. [41]NSNS Powell et al. [41]NSNSPrevious diagnosis of schizophrenia
Levi et al. [49]6.165.95 Lin et al. [43]0.300.42Psychotic symptoms versus. no psychotic symptoms
Roy & Draper [54]NS Levi et al. [49]5.663.82
Large et al. [58]1.931.93 Roy & Draper [54](+) Increased risk if schizophrenia disorder
Comorbid substance abuse Shah et al. [55](+) Increased risk if schizophrenia disorder
Madsen et al. [16]NSNSSecondary diagnosisLarge et al. [58]2.481.65
Hunt et al. [27]NSNSHistory of substance misuseComorbid personality disorder
Krupinski et al. [35]NS Addiction to alcohol or drugsMadsen et al. [16]1.721.60Comorbid personality disorder
Read et al. [39]NS History of alcohol/drug abuseHunt et al. [27]1.58NSAny secondary psychiatric diagnosis
Dong et al. [40]NSNSHistory of substance misusePowell et al. [41]NSNSPrevious personality disorder
Powell et al. [41]0.2NSCurrent drug abuseKing et al. [57]NSNSAdditional axis II disorder
Powell et al. [41]0.20.2Current alcohol abuse
Levi et al. [49]1.67NSAbuse at admissionPlanned admission
Roy & Draper [54]NS Alcohol/drug abuseKing et al. [57]NSNS
King et al. [57]NSNSHistory of problem drinking
King et al. [57]NSNSHistory of substance misuse
Large et al. [58]NS
Depressive symptoms Compulsory admission
Hunt et al. [27]1.60NSAt last contactMadsen et al. [16]NSNS
Dong et al. [40](+)NS(+) depr.sympt. adm. increased riskHunt et al. [27]0.43NS
Dong et al. [40] 8.53At time of suicideGale et al. [34](+) Increased the suicide risk
Taiminen et al. [38] 8.55Depressive symptoms at admissionKrupinski et al. [35]NS
Powell et al. [41]3.1NSDepressed moodRead et al. [39]5.5
Lin et al. [43]4.912.11 Dong et al. [40]NSNS
Steblaj et al. [44] 11.94For pt. with schizophreniaPowell et al. [41]NSNSPreviously detained under Mental Health Act
Steblaj et al. [44] 38.47For pt. with affective psych.osisRoy & Draper [54](+) Increased the suicide risk
King et al. [57]2.2823.45Depressive symptomsKing et al. [57]3.2749.83Wide CI for adjusted estimate
Large et al. [58]3.922.34Depressed mood at admissionLarge et al. [58]1.87NS
Recent DSH Psychiatric history
Madsen et al. [16]4.054.99 Hunt et al. [27]NSNSDuration of illness <12 month
Hunt et al. [27]3.31NS Hunt et al. [27]NSNS>5 previous admissions
Modestin et al. [30](+)(+)DSH increased riskModestin et al. [30](+)NSMental illness >5 years
Spiessl et al. [37] NS Krupinski et al. [35]NS Last admission within last year
Dong et al. [40] 3.92 Taiminen et al. [38]NSNSTotal No. of admissions
Powell et al. [41]14.3 Read et al. [39]NS Prior psychiatric admissions
Li et al. [45]5.17 Dong et al. [40]NSNSDuration of illness <12 month
Levi et al. [49]4.102.59 Powell et al. [41]2.32.5One or more previous admissions
Modestin & Kopp [53] (+)DSH increased risk Powell et al. [41]2.72.9Chronic mental ill (>5 years)
Shah et al. [55](+) DSH increased riskSteblaj et al. [44]NS Mean duration of illness
King et al. [57]3.951.26 Li et al. [45](+) Suicide associated with more previous admissions
Large et al. [58]2.412.26 Levi et al. [49]1.311.16No. of hospitalizations
Modestin & Kopp [53] (+)Mean Number of previous admissions. increased risk
Modestin & Kopp [53] NSDuration of psychiatric illness
History of DSH Sharma et al. [56]NS Mean no. of previous admissions
Madsen et al. [16]1.361.91 King et al. [57]NSNSLength of psychiatric illness
Hunt et al. [27]4.305.93 King et al. [57]NSNSPrevious admissions (0 vs. 1 vs. >1)
Modestin et al. [30](+)NS(+) DSH increased riskLarge et al. [58]1.811.58Median No. of admissions
Krupinski et al. [35](+) DSH increased risk
Neuner et al. [36] 4.34
Spiessl et al. [37] 5.6
Taiminen et al. [38] (+) DSH increased risk
Read et al. [39]3.6
Dong et al. [40] 4.60
Powell et al. [41]3.42.2Only significant for patients with schizophrenia
Modestin & Kopp [53] NS
Roy & Draper [54](+) DSH increased risk
Shah et al. [55](+) DSH increased risk
Sharma et al. [56](+) DSH increased risk
King et al. [57]2.23NS
Large et al. [58]3.953.30
CI: confidence interval; DSH: deliberate self-harm; NS: not statistically significant; OR: odds ratio; (+): statistically significant at the 0.05 level, no estimate reported, but direction of association described in Comment section.
Back to TopTop