Suicide risk after psychiatric hospital discharge

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suicideriskwebPatients discharged from psychiatric hospitals had higher short-term risks of suicide if they were diagnosed with depression, schizophrenia or bipolar disorder and were not connected to a health system for care, according to a Columbia University study.

Understanding which mental health disorders and other patient characteristics put patients at highest short-term risk for suicide after psychiatric hospital discharge can help guide interventions to prevent suicide.

Dr Mark Olfson, of Columbia University, New York, and co-authors used Medicaid claims data to examine suicide risk during the first 90 days after discharge for adults with diagnoses of depressive disorder, bipolar disorder, schizophrenia, substance use disorder and other mental disorders in comparison to inpatients with diagnoses of non-mental disorders.

The study population of more than 1.8m individuals included 770,642 adults with mental disorders and nearly 1.1m adults with non-mental disorders. There were 370 deaths from suicide from 2001 to 2007.

The short-term suicide rate in the group of adults with mental disorders was 178.3 per 100,000 person-years while the suicide rate of the US population demographically matched to the group of adults with mental disorders was 12.5 per 100,000 person-years, the study reports.

The highest short-term rate of suicide was among those adults diagnosed with depressive disorder (235.1 per 100,000 person-years), followed by bipolar disorder (216 per 100,000 person-years), schizophrenia (168.3 per 100,000 person-years) and other mental disorders (160.4 per 100,000 person-years), while the lowest was among those with substance use disorders (116.5 per 100,000 person-years), the results show.

The 90-day rate of suicide was nearly twice as high for men with any mental disorder as for women. Psychiatric inpatients without any outpatient health care in the six months before hospital admission also were at an increased risk for suicide, the study reports.

Limitations to the study included no way to validate mental health diagnoses in the Medicaid claims data. Results also may have differed if privately insured and uninsured patients had been included in the analysis. Information on other factors also was not available, including family history of suicide.

“These patterns suggest that complex psycho-pathologic diagnoses with prominent depressive features, especially among adults who are not strongly tied into a system of care, may pose a particularly high risk. As with many studies of completed suicide, however, the low absolute risk for suicide limits the predictive power of models based on clinical variables. These constraints highlight the critical challenge of predicting suicide among recently discharged inpatients based on readily discernible clinical characteristics,” the study concludes.

Importance: Although psychiatric inpatients are recognized to be at increased risk for suicide immediately after hospital discharge, little is known about the extent to which their short-term suicide risk varies across groups with major psychiatric disorders.
Objective: To describe the risk for suicide during the 90 days after hospital discharge for adults with first-listed diagnoses of depressive disorder, bipolar disorder, schizophrenia, substance use disorder, and other mental disorders in relation to inpatients with diagnoses of nonmental disorders and the general population.
Design, Setting, and Participants: This national retrospective longitudinal cohort included inpatients aged 18 to 64 years in the Medicaid program who were discharged with a first-listed diagnosis of a mental disorder (depressive disorder, bipolar disorder, schizophrenia, substance use disorder, and other mental disorder) and a 10% random sample of inpatients with diagnoses of nonmental disorders. The cohort included 770 643 adults in the mental disorder cohort, 1 090 551 adults in the nonmental disorder cohort, and 370 deaths from suicide from January 1, 2001, to December 31, 2007. Data were analyzed from March 5, 2015, to June 6, 2016.
Main Outcomes and Measures: Suicide rates per 100 000 person-years were determined for each study group during the 90 days after hospital discharge and the demographically matched US general population. Adjusted hazard ratios (ARHs) of short-term suicide after hospital discharge were also estimated by Cox proportional hazards regression models. Information on suicide as a cause of death was obtained from the National Death Index.
Results: In the overall population of 1 861 194 adults (27% men; 73% women; mean [SD] age, 35.4 [13.1] years), suicide rates for the cohorts with depressive disorder (235.1 per 100 000 person-years), bipolar disorder (216.0 per 100 000 person-years), schizophrenia (168.3 per 100 000 person-years), substance use disorder (116.5 per 100 000 person-years), and other mental disorders (160.4 per 100 000 person-years) were substantially higher than corresponding rates for the cohort with nonmental disorders (11.6 per 100 000 person-years) or the US general population (14.2 per 100 000 person-years). Among the cohort with mental disorders, AHRs of suicide were associated with inpatient diagnosis of depressive disorder (AHR, 2.0; 95% CI, 1.4-2.8; reference cohort, substance use disorder), an outpatient diagnosis of schizophrenia (AHR, 1.6; 95% CI, 1.1-2.2), an outpatient diagnosis of bipolar disorder (AHR, 1.6; 95% CI, 1.2-2.1), and an absence of any outpatient health care in the 6 months preceding hospital admission (AHR, 1.7; 95% CI, 1.2-2.5).
Conclusions and Relevance: After psychiatric hospital discharge, adults with complex psychopathologic disorders with prominent depressive features, especially patients who are not tied into a system of health care, appear to have a particularly high short-term risk for suicide.

Mark Olfson; Melanie Wall; Shuai Wang; Stephen Crystal; Shang-Min Liu; Tobias Gerhard; Carlos Blanco

JAMA material
JAMA Psychiatry abstract
JAMA Psychiatry editorial

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