The main finding of our study was that AUD was not associated with psychiatric admissions. This also underlined a discrepancy in the consideration of AUD and other psychiatric diagnoses such as depression and bipolar disorders, which were associated with more inpatient referrals.
Factors associated with psychiatric hospitalization
Depression was the main predictive factor of psychiatric inpatient care. Depression is also the most common psychiatric disorder in suicide attempters [
28,
29]. This was also the case in our study, with it accounting for 48% of all psychiatric diagnoses. Bipolar disorder was independently associated with increased hospitalization. This is unsurprising, as it is known to be associated with suicide attempts or death by suicide [
30]. Contrary to a previous study [
19], schizophrenia and personality disorder were not associated with psychiatric inpatient care in our sample. In relation to the former, this could be due to the small representation (only 3% of patients) of this diagnosis in our study.
In our sample, 20.16% of patients suffered from a borderline personality disorder. This is relevant because, personality disorders, especially borderline personality, are commonly observed among individuals who attempt suicide. We found no association between personality disorder and inpatient referral. This could be explained by the fact that the role of hospitalization after suicide attempts has generated controversy. One group advocates that hospitals keep patients safe and are appropriate for the treatment of co-morbidities, diagnosis clarifications and simplifying prescription medications [
31,
32]. Others point out that minimal evidence exists concerning the efficacy of hospitalization for chronic suicidality. Moreover, hospitalization can result in negative consequences for patients with a borderline personality, including behavioral regression [
33].
In terms of the data regarding suicide characteristics, and in parallel with the results of [
8], we found that a previous suicide attempt was associated with impatient care, as was suicidal intent.
Surprisingly, we found no association with sociodemographic characteristics, despite previous studies finding a link between male gender and psychiatric inpatient care. One explanation could be a recruitment bias among suicide attempters, as we only recruited the self-poisoning population, which comprised a large majority of women (68%). However, the careful evaluation of other important clinical variables (suicide intent, psychiatric disorder and sociodemographic) has tempered the gender effect.
BACs were not associated with inpatient orientation, which is probably explained by the fact that the patient assessment is only performed when the estimated BAC is below 0.05 g/L.
AUD is also a well-recognized suicide risk factor, but was not associated with psychiatric inpatient care decisions in our sample. We also found no association between BACs and the decision to hospitalize.
This finding underlines the fact that, in our center, AUD is considered differently to depression in clinician decisions, whereas previous studies found a similar suicidal risk increase with a depression or AUD diagnosis (respectively OR = 2.2 and OR = 2.4) [
34]. Since the decision to treat a suicide attempter as an outpatient is often due to these diagnoses, we performed an analysis on the sample excluding personality disorders and achieved a similar result to that for the entire population. This tends to confirm that AUD is considered differently to depression, even if patients do not suffer from a personality disorder.
Comparing patients with depression and co-morbid AUD, we found that they were less often referred for inpatient care than non-AUD patients (46.4% versus 53.5%).
Moreover, care referrals depended on the level of the risk of repetition, and AUD is related to multiple suicide attempts [
35,
36] and rapid reattempts, as 50% of patients plan their suicide attempt less than 1 week before it takes place [
37‐
39], although unplanned suicide attempts can still be deadly [
40]. In addition, alcohol intoxication could promote a suicide attempt because of its disinhibitory effect [
38,
39], and patients with AUD are at risk of alcohol consumption, including after a suicide attempt.
A longer period of follow-up is the most protective factor when it comes to preventing another suicide attempt [
41], which is why, in practice, a psychiatric evaluation needs to assess the effectiveness of outpatient care. Inpatient care after a suicide attempt does not lead to any reduction in the long-term suicide rate compared to outpatient care; in fact, the main protective factors consist of a care program independent of inpatient or outpatient modalities [
28,
42,
43]. However, it has been shown that patients suffering from substance abuse, including AUD, have difficulty engaging in outpatient care [
44,
45]. This could therefore mean that inpatient care should be specifically considered during a suicide crisis in order to place the patient at a distance from alcohol, thereby reducing impulsivity, improving mood and promoting follow-up observance [
46,
47].
In our database, we found that patients with AUD had a higher risk of repetition than those without AUD. We also found that outpatient care reduced the repetition rate at 1 year in the AUD versus the non-AUD population. This result also led to consideration of inpatient referrals in this group. However, the study was not designed to evaluate repetition rates and we therefore only report retrospective descriptive data concerning the evolution at 1 year. This finding must therefore be confirmed by future studies that specifically focus on this issue.
The discrepancy between the impact of AUD and depression on clinician decisions also needs to be addressed. It could partly be explained by the stigmatization of patients with AUD. Indeed, AUD is the most judged behavior compared with other health conditions such as obesity, depression or schizophrenia [
48]. Previous studies reported in the literature demonstrated that AUD was less commonly regarded as a mental illness than depression or schizophrenia [
49]. Nevertheless, a previous study showed that holding a conception of AUD as a mental illness increased treatment access [
50]. In addition, a study including internal medicine residents found a lower regard for AUD patients than those with other common conditions [
51]. Further, previous data suggest that patients hospitalized for suicide risk who are judged to have a risk related to alcohol intoxication are discharged sooner than those who are not perceived to have a substance-related risk [
52]. This knowledge led to consideration of whether AUD is stigmatized and its implications for a clinician’s decision-making, including by psychiatrists, when it comes to treating suicide attempters. In our study, it is possible to hypothesize that different views of AUD and other psychiatric disorders could partly lead to care discrimination through a clinician’s decision not to associate AUD with admission to hospital.
A limitation of this study is that we did not take the types of care for other addictions into account. Other addictions are reported on less, suggesting that practitioners do not consider them when deciding the type of care that a patient requires. Another limitation is that this was a single center study and, despite this center evaluating patients using international guidelines, our observations could not be generalized to all patients seen in France after a self-poisoning suicide attempt. Despite self-poisoning accounting for 82% of suicide attempts in France, this population is very specific. For example, other groups, such as those who attempt suicide by hanging or the use of firearms, are mostly represented by men and are suicide methods associated with greater lethality. Moreover, previous studies have referred to heterogeneity in a population with AUD that is explained by different settings and different populations, leading us to emphasize that our findings are limited to patients with AUD who attempted suicide by self-poisoning [
33]. Another limitation is the study’s cross-sectional design, which does not enable us to argue that there is a causal relationship. Despite these limitations, the strength of the study is the exhaustiveness of the data, as all eligible patients (expect for three) admitted during the study period were systematically screened. Well-designed intervention studies are now needed to better characterize the possible implications of AUD stigmatization after a suicide attempt and to provide effective strategies to improve AUD consideration in self-poisoning patients.