Suicide in Psychiatric Hospital In-Patients

The British Journal of Psychiatry

Paper 2012.

Risk factors and their predictive power

  1. JOHN POWELL, MRCPsych,
  2. JOHN GEDDES, MRCPsych and
  3. KEITH HAWTON, FRCPsych
  1. MICHAEL GOLDACRE, MSc, FFHPM

+ Author Affiliations


  1. Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford

  2. ICRF/NHS Centre for Statistics in Medicine, Institute of Health Sciences, Headington, Oxford

  3. Unit of Health-Care Epidemiology, University of Oxford
  1. Dr John Geddes, Warneford Hospital, Oxford OX37JX. Tel: 01865226480, fax: 01865 793101, e-mail: john.geddes@psych.ox.ac.uk
  • Declaration of interest No conflict of interest. Financial support detailed in Acknowledgements.

Abstract

Background Psychiatric hospital inpatients are known to be at high risk of suicide, yetthere is little reliable knowledge of risk factors or their predictive power.

Aims To identify risk factors for suicide in psychiatric hospital in-patients and to evaluate their predictive power in detecting people at risk of suicide.

Method 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.

Results 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%.

Conclusions 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.

Psychiatric hospital in-patients are known to be at high risk of suicide (Appleby, 1992). The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness has identified in-patients as a priority group for whom service recommendations are most required, and has recommended that the risk assessment skills of clinical staff should be strengthened (Appleby et al, 1999a). There is a need to identify more clearly the factors that are associated with suicide among in-patients. However, suicidal behaviour is difficult to predict (Hawton, 1987; Geddes, 1999), and the risk factors in in-patients are not necessarily the same as the risk factors for suicide in other population groups. Uncontrolled studies of in-patient suicides cannot quantify such risk factors and there have been few case-control studies (Modestin et al, 1992; Read et al, 1993; Roy & Draper, 1995; Sharma et al, 1998). We report a study designed to identify potential risk factors and to assess their clinical utility in the prediction of suicide.

METHOD

Identification of subjects and controls

Using the Oxford Record Linkage Study (ORLS) (Goldacre et al, 1988) we identified all the people who died while patients in psychiatric hospitals in the counties of Oxfordshire, Berkshire, Buckinghamshire and Northamptonshire between 1963 and 1992. …The causes of death were checked from examination of clinical records. …Patients with dementia admitted for respite care were excluded from the control group as they were not considered to be representative of acute psychiatric admissions.

RESULTS

In the study period there were 117 deaths of psychiatric hospital in-patients in which a suicide or open verdict was given by the coroner.

Characteristics of people who committed suicide while in in-patient care

Characteristics of the suicides

As shown in Table 1, more suicides occurred at the weekend. …The most common method of suicide was drowning …More men than women used violent method. … Twenty-six per cent (n=25) of the in-patients not on leave were on formal nursing observations at the time of suicide, and two in-patients were under continuous observation

DISCUSSION

One of the most striking findings of the study is that some of the factors associated with suicide in the general population (being male, single, living alone, being unemployed, substance abuse) (Charlton et al, 1993), were not associated with suicides by hospital in-patients. …

Substance abuse was associated with a reduced risk of suicide: it may be that patients admitted for these problems are not as acutely mentally ill (often being admitted for detoxification) as some other patients and do not have the same suicide risk.

Prediction and prevention of suicide by in-patients

The reason for identifying factors associated with suicide by in-patients is that such knowledge may be useful in helping to identify individuals at risk and to prevent suicides occurring. …

The suicide of a psychiatric hospital in-patient is a rare but important event. As well as the grief caused to family and friends, and the significant effects it can have on other patients, it also raises questions of responsibility and guilt for the professionals involved in caring for the patient. This study suggests that, unless a very high number of false positives is considered acceptable, it is unavoidable that clinicians will fail to identify before-hand a high proportion of suicides, even in a high-risk group such as psychiatric hospital in-patients.

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Retrieved 06/21/12. http://bjp.rcpsych.org/content/176/3/266.full

 

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6 Comments

  1. Jessica

     /  06/26/2012

    not while i was there but the ability to process the information needed to plan to do so was not something i think any of the patients i was helping could do. but it would have been easy to shield me from knowing the suicide amounts on the ward i was an aid to only a few patients.

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  2. Jessica

     /  06/25/2012

    ahh my hospital experiences were in wards for people with schizophrenia, where they were either actively hallucinating or catatonic so were always under watch.

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  3. Jessica

     /  06/25/2012

    curious how could the most used method be drowning, when in most inpatient units anything having to do with bathrooms or sinks is monitored.

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    • Beats the heck out of me how patients are drowning. Perhaps there are beautiful lakes and ponds on these estates.

      In my experience, baths and sinks are not monitored all the time. Patients in psychiatric hospitals have a lot of time to think and think they/we do! There are all kinds of hazards in a hospital that don’t take much to discover.

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