Preventing post-discharge suicides in psychiatric patients: insights from patients, lay healthcare supporters, and mental health professionals—a qualitative analysis

Suicide is a global significant public health issue. According to World Health Organization (WHO), there are approximately 703,000 individuals died by suicide annually worldwide, and the global age-standardized suicide rate is about 9.0 per 100,000 people in 2019 [1]. Global efforts are required to achieve one of the Sustainable Development Goals (SDGs) set by the WHO, which is to decrease one-third of suicide by 2030 [2, 3]. China has made great efforts, and the suicide rate in China dropped to 7.09 and 4.31 per 100,000 people in rural and urban in 2021, respectively [4].

The morality rate of individuals with mental disorders is five times higher than that of the general population, with suicides contributing to 40% of these fatalities [5, 6]. Notably, patients discharged from psychiatric facilities face significant greater suicide risk, and the pooled rate was 484 per 100,000 people in the first 12 months after discharge in UK, which can be up to 2950, 2060 and 1132 per 100,000 people in the first week, the first month and three months after discharge, respectively, according to research in England, Wales and America [7‐10]. However, we know of only one study in China reported a 12-month suicide mortality rate of 1062/100 000 among patients discharged from psychiatric facilities [11] In addition to the high prevalence, there is established information about risk factors associated with post-discharge suicide among psychiatric patients. While little is known about the risk factors in the context of China, there have been research worldwide that provide some insights. Commonly reported risk factors include gender, age, education, physical health, history of suicide attempts, etc., and we used the social ecological model to contextualize commonly studied risk factors (see Table 1) [8, 12‐30].

Existing studies on suicide underscores the premise that suicidal behaviors are frequently driven by intense emotional states perceived as intolerable by individuals which can be described by a spectrum of terms including anguish, desperation, mental pain, emotional dysregulation, annihilation anxiety, and isolation [31‐35]. Though some studies indicated that hospitalization could provide temporary relief from these feelings, it does not necessarily reduce suicide risk in the long term [36]. Patients often experience existential angst and dread upon discharge, as they are faced with the daunting prospect of leaving the supportive environment of the hospital and returning to their daily lives. They may feel disconnected from others and uncertain about their abilities to cope with stressors that may have contributed to suicide attempts, challenges that may reintegrate into their regular lives, possible relapses in the future, and stigma related to mental health problems [36‐38]. Thus, it is important to implement structured transitional mental health care services to support patients after psychiatric admissions [39].

Evidence-based guidelines recommend integrated interventions to reduce post-discharge suicide among psychiatric patients, which involve suicide risk assessment, safety planning, medication, psychological and behavioral therapy, regular follow-up, health education, emergency intervention system, and collaborative care from lay healthcare supporters (LHSs) and mental health professionals (MPs) [40‐42]. However, systematically implementing the interventions requires adequate mental health care service resource. Given there were only about 5.47 psychiatric professionals per 10,000 people in China, compared to 38.78 in Korea, 11.9 in Japan and 10–20 in many European countries [43, 44]. For individuals with severe mental disorders including schizophrenia, schizoaffective disorder, paranoid psychosis, bipolar disorder, psychotic disorders due to epilepsy or intellectual developmental disorder with psychotic disorders, they will be rated from levels 0–5 for the risk of violent behaviors and will receive follow-ups from community mental health workers. The frequency of the follow-ups will be weekly, bi-weekly and monthly based on the ratings; and the follow-ups is primarily to prevent violent behaviors towards the public rather than post-discharge suicide [45]. For individuals with other mental disorders, they will receive follow-ups from community mental health service providers only if they are identified as suicide risks by clinical physicians in the management system. Patients not flagged for suicide risk will need to proactively initiate contact with mental health intervention personnel to access suicide risk interventions [4, 45].

Thus, it’s important to develop and implement interventions adapted to the context in China. Further, we notice that most interventions are designed or implemented from a top-down approach, rather than being patient-centered, and only a few have considered the problems that patients may face after discharge and their needs [46, 47]. Hence, to help develop patient-centered policies and interventions to reduce post-discharge suicide risk among psychiatric patients, this study aims to explore problems faced by patients after discharge and their needs from the perspectives of patients and lay healthcare supporters who are usually patients’ family members and friends. Additionally, the study will incorporate insights from mental health care providers and policymakers, whose input is vital for improving intervention quality and efficacy, and for promoting a collaborative environment of empowerment, engagement, and trust between service users and providers.

A total number of 45 participants were recruited, including 17 patients, 8 LHSs and 20 MPs. We conducted 25 personal in-depth interviews and 3 focus group interviews. The duration of the in-depth individual interviews ranged from 16 to 64 min, with an average length of 47 min. The focus group interviews ranged from 28 to 35 min, with an average length of 32 min. Patients aged from 20 to 58 years, with a mean of 32.94 ± 10.71 years; LHSs aged from 23 to 50 years, with a mean of 39.75 ± 9.55 years; MPs aged from 25 to 51 years, with a mean of 34.15 ± 7.05 years. Details were showed in Table 2.

A total of 178 codes were generated, including 57 codes for post-discharge problems, and 121 codes for needs related to reducing suicide risk. Among the codes, 162 codes (91.2%) achieved consensus among all three analysts, 10 codes (5.5%) required discussion among the analysts, and 6 (3.3%) required a decision from the project leader. Details were showed in Tables 3 and 4. Only one representative verbiage for each code is featured in Tables 3 and 4, while all other participant verbiages and explanatory details are in the Supplementary additional file.

We deliberately employed a qualitative approach of descriptive interview as it enabled a deep exploration of participants’ personal experiences, and we identified a range of problems related to patients’ immediate surroundings at different levels: 1) problems related to self, 2) family-related problems, and 3) societal and community-related problems. We also found the unmet needs extended beyond the professional support provided by MPs and the emotional support offered by family members: 1) proactive self-management, 2) multifunctional relatives, 3) multifunctional MP group, and 4) a warm society, and post-discharge follow-up is essential to meet the unmet needs. During these follow-up contacts, MPs provide disease-related health education and empower LHSs to complete family-based intervention, as well as provide emotional and most professional support. Moreover, patients in this study acknowledged their positive roles in recovering, and we believed it shed light on help them take initiatives and implement practical steps to reduce post-discharge suicide. As far as we know, this study is one of the few studies in China that qualitatively takes a comprehensive approach involving psychiatric patients, their LHSs, and MPs. By exploring their perspectives, we addressed the post-discharge problems and unmet needs of patients in the context of post-discharge suicide management, with the goal of developing patient-centered strategies. Moreover, the same methodology of this study could be applied to examine the experiences and emotions of other populations, such as IPV victims [56].

We find that problems after discharge cross the social-ecological framework, and are similar to studies in other cultures that concerning to adaption to life, family relations, inadequate aftercare, social connection and government benefits and information [36, 57‐60]. Without a doubt, the problems and challenges would increase in the severity of symptoms and the risk of post-discharge suicide, and, according to a systematic review, we believe restricting access to lethal means, medication and psychological therapy, public and physician education, and internet or hotline support are important to for discharged patients and their LHSs [61]. We believe patients, LHSs and MPs should collaborate closely to ensure adherence to medication regimens and make necessary adjustments through regular follow-ups and monitoring, and we suggest patients engage in group activities that can alleviate the overcoming feelings of self-isolation. In addition, we encourage patients to engage in psychological and therapeutic interventions that specially address personal problems they would face within intimate relationships. Meanwhile, our findings suggest family-based interventions after discharge, including education LHSs about the illness, can help foster mutual understanding between patients and LHSs and prevent family conflicts.

Our findings suggest that though emotional support provided by LHSs and professional support offered by MPs are valuable, they may not fully meet the comprehensive needs of patients and, thus, have limited effectiveness in reducing post-discharge suicide risk among patients. Firstly, from the perspectives of patients and LHSs who received mental health care services, their expectations of MPs extend beyond professional support alone. They also value emotional support from MPs, including caring, companionship, and active listening. Previous studies have reported that poor relationships between patients and clinicians were associated with increased suicide risk, thus, we believe MPs can help reduce the risk by providing both indirect professional support and emotional support that builds supportive doctor-patient relationships [19, 36]. Secondly, MPs expect patients and LHSs to better understand mental disorders so as to improve medication adherence and accept post-discharge follow-up care. However, the effectiveness of community follow-up care in reducing suicide risk has yielded inconsistent findings, likely due do different continuity of care, social and cultural factors, and potential selection bias [13, 14, 18, 27]. Nevertheless, the findings indicate that many current approaches to psychiatric aftercare are inadequate. For patients who refuse follow-up care and post-discharge management, MPs should respect their choices while strengthening pre-discharge education and providing alternative monitoring measures such as accessible intervention resources. It is also important to remind LHSs to prioritize family care. Thirdly, we notice that patients believed that LHSs equipped with the necessary knowledge and skills for family-based interventions in psychiatric care and suicide prevention can significantly contribute to reducing post-discharge suicide risk. Given the shortage of mental health resources in China, empowering LHSs with professional knowledge for family-based interventions can effectively complement some of the services that are lacking in the community [4]. Fourthly, by emphasizing the importance of patients’ self-initiatives, we believe LHSs and MPs should pay attention to increase patients’ self-empowerment that is to increase patients’ autonomy, competency over life, and relatedness by improving their extrinsic and intrinsic motivations [62, 63]. In conclusion, to effectively reduce post-discharge suicide risk among patients, it is of great importance to address the roles of LHSs and MPs in a professional yet familial manner and in a continuum of collaborative mental health services that span across communal and societal sectors, with patient-centered follow-up care at its core.

In this study, participants emphasized the tangible support from community and society, such as financial assistance, employment opportunities, fostering a warm and accepting living environment for patients. In specific, patients expressed their hope for a less stigmatizing and discriminatory community and societal environment regarding mental illnesses, which would facilitate their recovery of social functioning and improve acceptance of follow-up care. Achieving such a supportive environment largely depends on the dissemination and promotion of knowledge about mental illnesses by MPs and the media at a broader societal level. These findings were aligned with evidence-based guidelines, which provide a strong foundation for promoting effective mental health care and suicide prevention [40‐42]. However, we acknowledge the implementation gap between the guidelines and the current reality, and we encourage efforts from sectors of health, social welfare, social safety, public affairs, and governance etc., to bridge the divide.

In this paper, we share a unique perspective on the problems and needs related to post-discharge suicide as perceived by psychiatric patients, LHSs and MPs. The findings highlight several key areas where patients face significant difficulties, including cognitive problems, outlook on life and the world, family conflicts and bonding, social communication, employment, and housing issues. Their unmet needs concerning to stakeholders including themselves, their LHSs, MPs as well as the broader community and society. The results indicate future interventions should involve all stakeholders as a cohesive system. Patients should be actively involved in the development of interventions, taking an empowered role in their own care. LHSs should acquire enhanced professional knowledge to effectively facilitate family-based interventions. MPs, in addition to providing professional support, should provide emotional support and some convenient services for patients and their families as well. Furthermore, media, policymakers, and the public should collaborate in creating a supportive environment that promotes patients' well-being and reduce the post-discharge suicide risk.