The characteristics of suicides within a week of discharge after psychiatric hospitalisation – a nationwide register study

A psychiatric illness that necessitates hospitalisation is one of the strongest risk factors for suicide [1]. Although the specific risk factors of psychiatric patients for completed suicide are not well established, the time period after discharge from a psychiatric hospital is known to be a high risk time for attempted and completed suicide for up to one year [2‐8]. A clustering of suicides within the first month and especially the first week after discharge seems evident [4, 9]. The factors associated with immediate post-discharge suicides are not well known, although it has been suggested that young adults, females, and those with affective disorders or short hospitalizations are at higher risk [9, 10]. Identifying subjects who carry a risk for immediate post-discharge suicide is particularly important given the current tendency to further shorten psychiatric hospitalizations. In terms of suicide prevention it is possible that identification of an obvious suicide risk and consequent actions may lead to prevention of suicide at least in individual cases. Postponing a potentially lethal suicide attempt ("winning time") may offer opportunities for effective treatment and suicide prevention. In addition to the relatively unspecific risk factors reported for immediate post-discharge suicide [10], more specific characteristic can be distinguished by exploring these suicides within the population of all previously hospitalized suicide completers.

Within the MERTTU project on the effectiveness of mental health services, we set out to investigate the nationwide pattern of post-discharge suicides and factors associated with suicides in the period subsequent to inpatient care. In a comprehensive, register-based database we had data on all completed suicides between 1980 and 2001 and any psychiatric hospitalisations that preceded their death. We aimed at characterising the victims of immediate (within one week) post-discharge suicides compared to victims who committed suicide later than the first week who had also had some previous psychiatric hospitalisation.

A proportion of 6% (1407/22717) of all suicide victims had died within a week of being discharged after a psychiatric hospitalisation. Compared to other previously hospitalised suicide victims, those committing suicide within a week of discharge were more often female, unmarried, and more likely to have used drowning, jumping or hanging as suicide methods (Table 1). They suffered more often from schizophrenia spectrum or affective disorders, and less often from substance-related disorders. They had also more often and for longer periods been in involuntary care according to the Mental Health Act during the last hospital period (mean of sum 25.7 days vs. 11.9 days, independent samples t-test, F = 40,59, p < 0.001). No differences were found in the frequency of individual coercive treatment acts, including injected medication, restrictions or constraint.

Typical for immediate post-discharge suicides was a more modest improvement between arrival and discharge in functional status as measured by GAS scores (3 vs. 16, t-test for means, t = 16.63, two-tailed p < 0.001), as well as a worse functional status (42 vs. 57, t-test for means, t = 18.97, two-tailed p < 0.001), though this information is only available among the more recent cases.

In this register-based study we collected a comprehensive dataset covering all suicides in Finland during 1980–2001. On the basis of the available information on previously hospitalised victims, we found that subjects committing suicide soon after discharge from hospital treatment for psychiatric disorders differed from later suicides of previously hospitalised patients in more often being female, having more often received treatment for a schizophrenia spectrum or affective disorder and less often for a substance-related disorder. They had more often used suicide methods of easier availability (particularly drowning and jumping from heights), had more often been an employee, and had more often had a higher grade of education. Their psychological functioning improved less during the last hospital period than the functioning of subjects who committed suicide later. They were more often involuntarily treated, and they also had worse GAS scores at discharge. These findings from a comprehensive nationwide suicide population help in efforts to characterise psychiatric inpatients at risk for immediate suicide after discharge, and in adding to our understanding of the role of their hospitalisation and post-hospital follow-up. These individuals may represent patients whose discharges should be particularly well-planned and monitored.

The distinctive characteristics we found are not specific for suicides in general and they do not represent suicide risk factors. They rather help to identify a special population comprising a total of 6% of all suicides, a part of which we believe, could be prevented by alertness in mental health in-patient services. A better recognition of risk and prevention of immediate post-discharge suicides may act towards winning time for appropriate management of effective care. It may be that a final set of risk factors at the time of immediate post-discharge suicide are no longer valid when sufficient time has passed. In this regard, a successful recognition of risk among this special population offers a means for effective suicide prevention in a portion of potential suicide attempters. For instance, a portion of the immediate post-discharge suicide victims may have suffered from a relatively fast decline in their psychiatric and psychosocial condition. This disruption may have gone unnoticed and a relatively premature discharge has occurred. In these cases, a longer treatment period and the management of proper aftercare, including family support, might have been preventive for suicide [10].

Our findings indicate that in retrospective, suicides soon after discharge after a psychiatric hospitalisation have some typical characteristics that indicate a more severe psychopathology, a lower level of functioning, and a preferential choice of more lethal and easily available methods for suicide. These suggest the possibility of better recognition during treatment, and for preventive efforts in selected populations. With regard to suicide prevention, there is a need for a better recognition of suicidal risk among psychiatric patients during a period of decreased total use of psychiatric hospital treatment. Most likely, immediate follow-treatment for discharged patients is needed.