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Latest methods to reduce suicide risk after psychiatric hospitalization

June 7, 2012
by Tony Salvatore, MA
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Ironically, inpatient psychiatric care, the very thing that offers safety and stabilization to acutely suicidal individuals, leaves them at high risk of suicide after discharge. But a review of the latest research identifies practical prevention steps.
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A recent review of the National Suicide Prevention Strategy included this recommendation: “Expand efforts to provide effective follow up care after inpatient discharge of suicidal persons.”10 Another national report was more specific: “Adopt nationally recognized policies and procedures that best match patients at risk for suicide to follow-up services that begin at or near the time of discharge from … an inpatient psychiatry unit.”11

A national suicide prevention organization issued a broader advisory:12

  • Pre-discharge assessment of risk at admission and risk acquired during stay.
  • Identify sources of support and willingness and ability to provide support.
  • Give patient and family instruction on suicide risk at discharge and thereafter.
  • Give instruction on accessing crisis intervention and other sources of help.

Bumgarner and Haygood call for the use of a “risk reduction pathway” involving a “bundle” of suicide prevention practices provided to every patient, which at discharge would include:13

  • Suicide risk assessment to inform the discharge decision
  • Communication of risk/prevention measures to patients and family members
  • Follow-up with patients after discharge
  • Supports and services in place after discharge

Other resources that come to mind are: 

  • Preparation of personal suicide prevention of safety plans at discharge.
  • The availability of peer-run warm lines for use by newly discharged consumers.
  • Access to therapies that have demonstrated suicide prevention potential (e.g., Cognitive Behavioral Therapy).
  • Peer-led or co-led support groups for those who have made suicide attempts or had an acute episode of suicidality.
  • Training peer specialists as “gatekeepers” to identify possible warning signs of suicide in other consumers.

Inpatient providers must do more to reduce the risk of “outpatient” suicide. Montgomery County Emergency Service, a 73-bed nonprofit psychiatric hospital, has inaugurated a number of easy-to-replicate practices in recent years. These include a range of suicide prevention education materials for consumers and families, a peer-led inpatient suicide prevention support group, “special discharge instructions” on suicide risk, and tighter pre-discharge risk assessment.

Community-based providers must also help make post-discharge suicide what the National Action Alliance for Suicide Prevention recently called a “never event.”14 In this regard, the Alliance has called for suicide risk screening to be universal in all behavioral health care settings and that suicide risk be seamlessly addressed along the care continuum until eliminated. This would extend a “risk reduction pathway” from inpatient admission to recovery.

In addition to reducing consumer mortality, a post-discharge suicide prevention effort may reduce readmissions and involuntary hospitalizations, both of which are driven heavily by suicidal behavior. Of course, it can also improve recovery prospects for inpatients while helping them maintain the hopeful outlook needed to motivate and maintain greater personal wellness.

Tony Salvatore, MA, is the suicide prevention specialist for Montgomery County Emergency Service, Norristown, PA. E-mail Tony at tsalvatore@mces.org.

References

1. Crawford, M. “Suicide following discharge from in-patient psychiatric care” Advances in Psychiatric Treatment 2004(10) 434-438.

2. Dennehy, J., Appleby, L., and Thomas, C. “Case-control study of suicide by discharged psychiatric patients” British Medical Journal 1996(312).

3. The Joint Commission, Sentinel Event Data, Event Type by Year, 1995-Third Quarter 2011. Retrieved on November 30, 2011 from http://www.jointcommission.org/assets/1/18/Event_Type_Year_1995_3Q2011.pdf

4. Litts, D., et al. (Eds.) Suicide Prevention Efforts for Individuals with Serious Mental Illness: Roles for the State Mental Health Authority. Alexandria, VA: National Association of State Mental Health Program Directors, 2008.

5. Meehan, J., et al. “Suicide in mental health inpatients and within 3 months of discharge” British Journal of Psychiatry 2006(188) 129-134.

6. Bongar, B. (Ed.), Suicide; Suicidal behavior; Personality Assessment; Risk factors; Diagnosis; Prevention New York, Oxford University Press, 1992.

7. Combs, S., and Romm, H. “Psychiatric inpatient suicide: A literature review” Primary Psychiatry 2007(14) 67-74.

8. Joiner, T. Why People Die by Suicide Cambridge, MA: Harvard University Press, 2005.

9. Priola, S., Sohlman, B., and Wahlbeck, K. “The characteristics of suicides within a week of discharge after psychiatric hospitalization – a nationwide register study” BMC Psychiatry 2005(5).

10. Litts, D. (Ed.), Charting the Future of Suicide Prevention: A 2010 Progress Review of the National Strategy and Recommendations for the Decade Ahead. Newton, MA: Education Development Center, Inc., 2010.

11. Knesper, D., Continuity of Care for Suicide Prevention and Research: Suicide Attempts and Suicide Deaths Subsequent to Discharge from the Emergency Department or Psychiatry Inpatient Unit. Newton, MA: Education Development Center, Inc. 2010.

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