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Pauline Anderson
Medscape Medical News 2008. © 2008 Medscape

November 21, 2008 — Two new studies show that patients who have attempted suicide or who have been hospitalized for a psychiatric illness are at increased risk for suicide or other types of self-harm. These findings, say experts, highlight the importance of, and the need for, immediate and effective aftercare interventions.

In the first study, investigators at the Karolinska Institutet in Stockholm, Sweden, found that the type of coexistent psychiatric disorder significantly affects the risk for a completed suicide after treatment for a suicide attempt.

The strongest psychiatric predictors of completed suicide during the 25-year follow-up period were schizophrenia and bipolar and unipolar disorder.

"Depression, especially severe depression, is already a known indicator of risk with and without previous suicide attempts, but the particularly high risk in schizophrenia and bipolar disorder is worth noting," principal investigator Bo Runeson, PhD, told Medscape Psychiatry.
In the second study, researchers at the University of Bristol, in the United Kingdom, found an increased risk for self-harm shortly after a stay in a psychiatric ward.

Risk for self-harm was greatest in the 4 weeks after disharge, with 32% of admissions for self-harm occurring during this period. "The new finding in our study is the high risk immediately after discharge," lead author David J. Gunnell, MBChB, PhD, told Medscape Psychiatry.
Both studies are published online November 18 in BMJ.

Highest Short-Term Risk Linked to Schizophrenia, Depression

In the first study, researchers followed 39,685 subjects (53% women) who had been admitted to hospital for attempted suicide from 1973 to 1982. Individuals were followed until 2003, and data from registries on hospital discharge, cause of death, and demographic information were linked.

Patients who had attempted suicide but who did not have a diagnosis of mental disorder were used as a reference group.

The researchers examined 8 psychiatric disorders: schizophrenia, bipolar and unipolar disorder, other depressive disorders, anxiety disorder, adjustment disorder or posttraumatic stress disorder, alcohol abuse or dependence, drug abuse or dependence, and personality disorder.

They found that a high proportion of completed suicides in all diagnostic categories, including the reference group, occurred in the first year after the suicide attempt. The highest short-term risk was associated with bipolar and unipolar disorder (64% of suicides in men and 42% in women) and schizophrenia (56% in men and 54% in women).

Although the risk for suicide was especially high during the first year after hospital discharge, it remained for the entire observation period of almost 25 years, said Dr. Runeson. Hazard ratios adjusted for age, education, and immigrant status ranged from 2.5 for bipolar and unipolar disorder among women, to 4.1 for schizophrenia in men.

The results translate into a risk for completed suicide among previous attempters with schizophrenia or depression that is about 3 times higher than that in suicide attempters without obvious psychiatric disorder, he said.

The risk for suicide was also notably higher for people with other psychiatric disorders, including personality disorder, anxiety disorder, and drug abuse.

Patients with schizophrenia or bipolar/unipolar disorder should receive dedicated aftercare, especially during the first 2 years after attempted suicide, to reduce their risk for suicide, the authors conclude.

Previous research by other groups has shown that patients with schizophrenia have a 10-fold higher suicide rate and those with bipolar disorder have a 20-fold higher rate than the general population. Studies also show that a previous suicide attempt poses a 30 to 40 times higher risk for completed suicide.

Self-Harm Another Postdischarge Risk
In the second study, researchers found that it is not just completed suicides that are a concern in the early period after discharge from a psychiatric hospital.

Here, Dr. Gunnell and colleagues studied 75,401 patients, aged 16 to 64 years, who were discharged from psychiatric care in England and Wales between April 1, 2004 and March 31, 2005, and followed them for 1 year. Of these, 4935 (6.5%) were admitted at least once for self-harm.

It is not clear why the risk for self-harm rises shortly after hospital discharge. However, possible contributors include "the return to the preadmission stressors, such as relationship problems, social isolation, and debt, after a period in a relatively protected environment on an inpatient unit, and reduced levels of supervision and support in the community," said Dr. Gunnell.

Hospital admission for self-harm in the previous year was the strongest risk predictor for subsequent self-harm, with approximately a 5-fold increased risk. This finding indicates that those who have already exhibited self-harm "should be the focus of increased vigilance in postdischarge care plans," he said.
The risk for self-harm was also increased in women; in young people; in those with depression, a personality disorder, or substance misuse; and in those who had a relatively short hospital stay.

Stay in Touch

"Practicing physicians need to be aware that patients who have recently been discharged from a psychiatric inpatient unit are at high risk for self-harm and suicide, particularly in the first days and weeks after discharge. It's important to stay in touch with them, ensure specialist follow-up is in place, and take other steps as appropriate to reduce risk," said Dr. Gunnell.

In an accompanying editorial, Udo Reulbach, MD, MSc, from the National Suicide Research Foundation, in Ireland, and Stefan Bleich, MD, from the Medical School of Hanover, in Germany, noted that up to 45% of patients who deliberately harm themselves are not adequately assessed after completing treatment. "Routine psychiatric assessment might be the most important initial step when organizing aftercare," they write.

Aftercare for patients with schizophrenia, depression, or bipolar disorder who have attempted suicide should also include education of the immediate family and friends, say the editorialists. They cited recent studies showing that contacting patients by phone 1 month after treatment for self-poisoning (one of the most common methods of attempted suicide) can reduce the number of repeat episodes.

It is estimated that by 2020, suicide will represent about 2.4% of the global burden of disease, with about 1.5 million deaths each year. Suicide prevention should be a public-health priority on medical, ethical, and cost effectiveness grounds, the authors write.


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