Preventing Suicidal Behaviour in a General Hospital Psychiatric Service: Priorities for Programming

Purpose: General hospital psychiatric services are able to provide leadership and coordinate the development of suicide prevention programs for individuals serviced in general hospital settings. We completed this literature review to suggest priorities for programming.

Methods: Our procedure was to update the review by Gunnell and Frankel that guided priorities for Health of the Nation, the national suicide prevention strategy in the UK. We completed a search, using the terms suicide prevention and control, of all English-language research and clinical trials conducted between January 1, 1994, and May 1, 2004.

Results: We identified 82 papers. Of these, 48 were excluded and the remaining 34 were grouped by secondary care setting categories. We found no articles on screening tools for predicting risk of suicide, 16 articles on interventions for individuals with suicidal behaviour, 14 articles on the treatment of major psychiatric disorders, 1 article and 1 published abstract on discharge from hospital, and 2 articles on reducing access to means.

Conclusions: Based on a review of each category, we make several program and policy recommendations, including regularly updating clinical assessment skills, using guidelines for assessment of patients following a suicide attempt, assessing the risk of suicide 24 to 48 hours before discharge from hospital, and incorporating education about reducing access to means into routine psychiatric care.

(Can J Psychiatry 2005;50:490^96)

Information on funding and support and author affiliations appears at the end of the article.

Clinical Implications

* Clinical assessment remains the gold standard in terms of suicide risk assessment.

* To decrease the risk of suicide, intensive programming should be developed for persons with recurrent suicidal behaviour.

* Professionals within general hospital psychiatric services need to be educated about treatments that are known to be effective in reducing suicide risk.

* Guidelines can be developed to ensure that patients with suicide risk are assertively followed up after discharge and that limits are placed on prescription quantities in high-risk patients.

* Education about reducing access to means should be incorporated as part of routine psychiatric care in all patients seen in general hospital psychiatric services.

Limitations

* We limited the search to English-language research and clinical trials.

* Although patients discharged from hospital form one of the highest risk groups for suicide, few interventions have been studied to guide policy development.

* We excluded studies drawn from communities, schools, primary care, and forensic or other settings because they were considered not applicable to a general hospital psychiatric setting.

Key Words: suicide prevention, psychiatric services, suicidal behaviour, discharge

The purpose of this review was to provide evidence to suggest priorities for suicide prevention programming in general hospital psychiatric services. In Ontario, the AGHPS represents 48 of 60 Schedule 1 psychiatric facilities. According to legislation, Schedule 1 facilities are required to provide essential psychiatric services, including inpatient, outpatient, daycare, consultation, and emergency psychiatric services. Given their mandate, general hospital psychiatric services and the AGHPS are well-placed to have an essential role in suicide prevention. First, more than 90% of suicide victims are known to have one or more psychiatric disorders at the time of their death-psychiatric disorders may be considered a necessary, although not sufficient, cause of suicide (1). Second, persons who attempt suicide who present to hospital services are at risk of death from suicide in the first year following the attempt-66 times the annual risk in the general population (2). Finally, evidence from a systematic review of the literature indicates that perhaps as many as 40% of individuals in the general population who died by suicide had documented inpatient psychiatric care within the year of their death (3 ). All this evidence indicates that people serviced within the general hospital psychiatric setting (as well as individuals with chronic medical illness, individuals who abuse substances, and the elderly) are at high risk for suicide because of their psychiatric illnesses and (or) suicidal behaviour. Thus general hospital psychiatric settings are appropriate targets for preventive initiatives.

Literature Review Process

To establish programming priorities, we updated the review by Gunnell and Frankel (4). The Gunnell and Frankel review provided priorities for the Health of the Nation preventive initiative in the UK. Using the search terms suicide prevention and control, the present review updated the search from January 1, 1994, to May 1, 2004. We limited the search to English-language research and clinical trials. Using this methodology, we identified 82 papers. For purposes of the review, we used the same categorization as the original Gunnell and Frankel paper. The articles were grouped on the basis of their relevance to the following 5 categories:

1. Screening tools for predicting risk of suicide: 0 articles.

2. Interventions for individuals with suicidal behaviour: 16 articles.

3. Treatment of major psychiatric disorders: 14 articles.

4. Discharge from hospital: 1 article and 1 published abstract.

5. Reducing access to means: 2 articles.

We excluded 48 papers from the review. The most common reason for exclusion was that the study sample was drawn from a community, a school, primary care, or a forensic or other setting not generally applicable to a general hospital psychiatric setting. One paper, initially excluded, was reconsidered and added to the category "interventions for individuals with suicidal behaviour" (5). We found one published abstract that was relevant, which we included in the "discharge from hospital" category (6). We present the results of the review under each of these categories. Appendix 1 provides a list of the reviewed papers by category. Certain additional references that we judged to have adequate methodology and implications for service delivery and policy development are considered in the body of the paper. The review concludes with a discussion of the priorities and implications for developing a suicide prevention strategy within general hospital psychiatric settings.

Literature Review Results

Screening Tools

We identified no research on the development of screening tools for individuals at risk of suicide that was relevant to psychiatric hospital settings. Because of this lack of research, clinical assessment is still considered the essential element of the suicide assessment process (7). No measurement scale has been developed that has adequate predictive validity to replace a clinical assessment by a skilled clinician (7). General hospital psychiatric services have to ensure that staff are trained in the clinical assessment of suicide risk and that their training is regularly updated.

Interventions for Individuals With Suicidal Behaviour

Hawton and colleagues completed a metaanalysis of treatments following deliberate self-harm as part of the Cochrane collaboration (8). This review identified 23 RCTs dealing with individuals following suicidal behaviour and includes the references up to 2000 found in this search. The Cochrane review included all age groups and was grouped according to expert consensus ratings by the common therapeutic strategies that were employed as the intervention. Hawton and others (8) identified that teaching problem-solving strategies vs standard aftercare led to significant improvement in depression and hopelessness and improvement in problem-solving skills but did not demonstrate a significant reduction in the recurrence of suicidal behaviour (OR 0.70; 95%CI, 0.45 to 1.11; ns). Outreach intensive interventions or improving access to care, compared with standard care, and antidepressant medication vs placebo following a suicide attempt also did not demonstrate significant effects on the rate of recurrence. However, one study of patients without psychosis and with 2 or more suicide attempts suggested that flupenthixol, a neuroleptic medication, vs placebo did reduce the risk of recurrence (OR 0.09; 95%CI, 0.02 to 0.50; significant). The potential of low-dose neuroleptics to prevent recurrence of suicidal behaviour was further tested by Battaglia and colleagues (9), who compared low-dose fluphenazine (12.5 mg) with ultra low-dose fluphenazine (1.5 mg) monthly in individuals with multiple suicide attempts presenting to emergency psychiatric services. Using a randomized control design, the authors found that both arms of the study produced marked reductions in self-harm behaviours during the trial period and that there was no evidence that the low dose was more effective than the ultra low dose (the placebo equivalent). On the psychotherapy front, Hawton and others found that the most promising therapeutic approach was dialectical behaviour therapy vs standard care (8), which was judged to have a significant effect on the reduction of suicidal behaviours in individuals with borderline personality disorder (OR 0.24; 95%CI, 0.06 to 0.93). These findings have been replicated several times in clinical trials, including adolescent samples, with dialectical-behavioural therapy or CBT demonstrating effectiveness in reducing suicidal ideation, suicidal behaviour, impulsivity, self-harm behaviours, and relapses of substance abuse (10-16).

Three additional approaches have been tested as interventions to prevent recurrent suicidal behaviour. Tyrer and others (17,18) tested an abbreviated form of CBT. Only 5 sessions were included, with bibliotherapy compared with treatment as usual for patients with recurrent self-harm behaviours. The study failed to find significant differences between the 2 approaches. Huey and others (19) found that multisystemic therapy, a community-based family-systems therapy, was significantly more effective in decreasing rates of attempted suicide in youth presenting to psychiatric emergency, compared with hospitalization. However, the youth assigned to multisystemic therapy started with significantly higher rates of attempted suicide than the comparison group; therefore, the findings may reflect a regression to the mean effect. Guthrie and colleagues (20) found a brief psychodynamic interpersonal therapy to be significantly more effective in reducing the risk of repeated attempts vs treatment as usual in a group of adults who presented to hospital with self-poisoning attempts.

Interventions have also been developed to improve treatment adherence following presentation to an emergency department; otherwise, as many as 75% of individuals will not follow through with outpatient follow-up (21). Spirito and others (22) failed to find a significant effect on adherence of a problem-solving intervention vs standard care in adolescents following a suicide attempt. However, Rotheram-Borus and others (23,24) evaluated a program to enhance treatment adherence in adolescents who had attempted suicide presenting to an inner city emergency department service. The program was successful at having adolescents attend 3.8 more therapy sessions on average than those exposed to the standard condition.

On the basis of these findings, we propose the following intervention recommendations for individuals with suicidal behaviours. First, more collaborative research is needed to realize the most effective interventions for individuals with presentations related to suicide attempts. Several jurisdictions have already developed guidelines for the assessment and active engagement of patients presenting with suicidal behaviour. Guidelines are available through the Royal College of Psychiatry in the UK (www.mentalhealth.org/ suicideprevention), in Australia and New Zealand (www.ranzcp.org/publicarea/cpg.asp; 25), and through the American Psychiatric Association (www.psych.org/ psychj_ract/treatg/pg/pg_suicidalbehaviors.pdf; 7). Our literature review provides evidence for the importance of staff training. Staff need to be aware of the risks to people with recurrent suicidal behaviour and the need for intervention. These educational resources are also needed for families, who must also be actively engaged to ensure compliance with follow-up. The engagement plan should include seeking permission to inform family physicians about their patients' presentation for suicidal behaviour.

The review supports the position that programs for treating individuals with recurrent suicidal behaviour should be developed. With the infusion of new resources, dialectical behaviour therapy or other problem-solving approaches warrant program development as potentially efficacious interventions for persons with multiple suicide attempts. The evidence points to the fact that the number of attempts may be an important parameter or moderator in determining effective interventions. Therefore, it is possible that individuals with a single attempt require less intense and different follow-up intervention than do those with a history of multiple attempts.

Treatment of Major Psychiatric Disorders

Providing adequate interventions for major psychiatric disorders is felt to have an important role in suicide prevention, but this broader topic is beyond the focus of this review. Two areas of research published in the last 10 years have demonstrated that specific treatments will decrease the risk of suicidal behaviour or suicide in persons with major psychiatric disorders. The first relates to the use of clozapine in individuals with schizophrenia at risk for suicide, and the second involves lithium maintenance therapy in patients with bipolar affective disorder.

Meltzer and colleagues (26,27) completed a unique study focused on patients with schizophrenia or schizoaffective disorder and judged to be at high risk for suicide. They selected patients aged 18 to 65 years (n = 980) with a history of high risk for suicidal behaviour and compared clozapine with olanzapine in these patients. The results suggested that there was a 26% reduced risk for suicide attempts or hospitalizations to prevent suicide in the clozapine- vs olanzapine-treated patients. This was a ground-breaking study: it directly studied suicidal behaviour as the outcome, and it demonstrated clear effectiveness of clozapine over the comparison treatment. The mechanism by which clozapine prevents suicide is unclear. It does not seem to be related to efficacy with treatment-resistant individuals, because most of these patients were not judged to be treatment-resistant. Clozapine may have an intrinsic antidepressant property or a specific effect on suicidality that is somewhat distinct from its effects on psychosis and depressive symptoms. Thus clozapine should be considered as indicated in individuals with schizophrenia who are judged to be at high risk for suicide.

When used for maintenance therapy, lithium has been purported to have an antisuicidal property in patients with bipolar affective disorder (28,29). This evidence comes from several sources. In an RCT comparing prophylaxis treatment with lithium vs carbamazapine in patients with bipolar and schizoaffective disorders, Kleindienst and colleagues (30,31) observed that there were no reported suicide attempts or suicides in the lithium arm, compared with 1 suicide and 5 attempts in the carbamazapine arm. In addition, using a pre-post design, Tondo and others (32) demonstrated that the risk of suicide before the lithium exposure was 6.5 times higher than following lithium treatment for bipolar affective disorder. Tondo and Baldessarini (33) have since reviewed several prospective studies, all of which found benefits for lithium in preventing suicidal behaviour, with a sevenfold difference in suicidal behaviour before, compared with after, exposure. Recently, using a retrospective cohort study design with data from 2 large managed care organizations, Goodwin and colleagues (34) compared the risk of suicide attempts and suicides during lithium or divalproex treatment in 20 638 health care plan members who were diagnosed with bipolar affective disorder and who filled at least 1 prescription for the above medication. The individuals were aged 14 years or over and were enrolled in the health plan that provided the study data. The authors found that the risk of suicide was 2.7 times higher during divalproex therapy compared with lithium therapy, again supporting an antisuicidal effect of lithium exposure. In summary, lithium seems to have an effect on reducing suicidal behaviour and suicide that is observed after the first few years of treatment. The risk is not eliminated completely; however, this risk reduction has not been demonstrated for other mood stabilizers. The authors of several of these reports also found a high risk for suicidal acts if lithium was discontinued, and this risk was highest during the first year of discontinuation.

Rucci and colleagues (35) documented the reduction in suicidal behaviour in patients with bipolar disorder who were followed with a combination of pharmacotherapy, mostly lithium, and psychosocial interventions within a specialized research clinic. The suicide attempt rate was reduced threefold during the acute phase and 17.5-fold during maintenance treatment, compared with the pretreatment period. Four recent studies of assertive community treatment produced counterintuitive findings because most experts have suggested that careful monitoring and early detection of suicide risk should have important implications for their prevention (36). These 4 RCTs demonstrated that assertive community treatment does not lessen the risk of suicide and suicidal behaviour, compared with more conventional treatment (37-40).

The implications of this research suggest that there are specific treatments for major psychiatric disorders that have the potential to reduce suicide risk. It is important that psychiatric personnel working in general hospital settings be educated about the indications for clozapine in individuals with schizophrenia at risk for suicide and for lithium maintenance therapy in patients with bipolar affective disorder at risk for suicide. Adequate and effective treatment for psychiatric disorders in general must be provided, although this topic is beyond the realm of the present discussion. Bertolote and others (41) suggested that the impact of effective treatment for major psychiatric disorders had the potential to save 165 000 lives in 2000 throughout the world. Although careful follow-up and monitoring of patients with major psychiatric disorders is an important part of psychiatric management, it may not be sufficient in some cases to reduce the risk of suicide. Specific programming that targets on-going risk factors such as hopelessness as part of the intensive follow-up may be needed to prevent suicide in these high-risk patients (42).

Reducing Risk on Wards and Among Discharged Patients

The literature reviewed provided evidence for the high risk in patients discharged from hospital and also revealed a report of a possible intervention strategy for discharged patients. Robinson and colleagues (6) published an abstract based on The National Clinical Survey (43), a survey of all suicides of individuals with mental health service contact in the year before their death in the UK. Of all the persons who died by suicide, 5099 (24% of all reported suicides) had contact with mental health services, and data were available on 4859 of these. According to this sample, 754 individuals had been psychiatric inpatients at the time of their death. Almost one-third of the suicides of psychiatric inpatients had occurred on the psychiatric ward, and of these deaths, 74% had been by hanging. The National Suicide Prevention Strategy in England (44) provided some practical guidelines based on the evidence from the National Clinical Survey. They suggested that all inpatient wards be regularly reviewed for safety, in particular, for possible ligature points that would put persons at risk.

In addition, the suicides tended to cluster in the first week or around discharge, with 23% occurring within 3 months of discharge. These data highlight the requirement for documentation of a patient's risk for suicidal behaviour at each major transition in the level of care provided. Motto and Bostrom demonstrated that simple contact by letter, suggesting the importance of "connectiveness," following discharge from hospital was sufficient to reduce the risk of suicide after discharge (45).

This research leads to some service recommendations for reducing risk in patients recently discharged. First, although this is one of the highest risk groups established, little intervention research has been carried out, and more studies are urgently needed. In addition, every patient with a history of suicidal behaviour requires a risk assessment 24 to 48 hours prior to discharge to ensure that the acute risk of suicide has been mitigated. The National Suicide Prevention Strategy recommends that follow-up within 7 days of discharge be in place for all persons with severe mental illness or a history of self-harm in the previous 3 months who are being released from an inpatient service. Patients with a history of self-harm in the last few months are also recommended to receive no more than 2 weeks of medication at discharge from hospital. The guidelines recommend the development of individual care plans to specify actions that should be taken if a patient is noncompliant or fails to attend follow-up appointments. Assertive outreach to prevent loss of contact, particularly with vulnerable or high-risk patients, is incorporated within the individual care plans.

Reducing Access to Means

Two studies were relevant regarding the issue of professionals educating individuals and families about the need to reduce access to means. Kruesi and others looked at the value of patient education in the emergency room (46). They examined prospectively a sample of children and families who were given a mental health assessment to determine whether parental receipt of education to limit access to suicide means led to actual action. The authors found a significant association between the educational input and action taken to limit access to means (OR 3.6; 95%CI,1.1 to 12.1). According to their evidence, adults were at least likely to take such modest actions as locking up firearms, even if they did not always dispose of them.

Brent and others evaluated the effectiveness of their recommendation to remove firearms during a clinical trial of adolescents being treated for depression (47). The parents of 106 adolescents were asked about the presence of firearms in the home as an initial part of their assessment. If the parents answered in the affirmative, they were given education about the need to remove the firearm(s) to prevent access to means. Of those with guns at study intake, 26.9% reported removing the gun by the end of the clinical trial. However, of those without guns at intake, and therefore not receiving education, 17.1% of the parents actually acquired firearms over the 2-year follow-up during the course of the clinical trial. The authors concluded that compliance was limited with this psychoeducational intervention, although the intervention did reduce access to means. The authors cautioned that families should be warned about removing access to firearms, because of the evidence that families acquired firearms, and that a need existed to develop more effective identification and interventions for families that had or would be likely to acquire guns.

The implications of this research suggest that reducing access to means needs further study so that more effective interventions can be developed. However, evidence exists that the simple intervention of providing education about limiting access to means should be incorporated into the care of all mental health patients.

Implications

This review suggests that several priorities for action can be developed for general hospital psychiatric services. Many of these actions can be undertaken currently; others may require the infusion of new resources. The implications for action are discussed below:

Screening Tools Predicting Risk of Suicide

Certainly, further research is needed to develop appropriate screening tools, or perhaps indicators of warning signs, for those at immediate risk for suicide. Our review indicates, as has been reiterated by the American Psychiatric Association practice guidelines (7), that clinical assessment remains the essential element of suicide risk assessment. Clinical staff within a general hospital psychiatric service must be trained, and their training updated regularly, to assess suicide risk. This training would be equivalent to the updating that regularly occurs regarding cardiac resuscitation.

Interventions for Individuals With Suicidal Behaviour

This high-risk group needs to be adequately assessed and observed. Policy and guidelines should be in place to assist both emergency personnel and mental health staff in providing adequate assessment and follow-up. Intensive programming should be developed for those with recurrent suicidal behaviour; evidence indicates that effective interventions are possible. These interventions involve dialectical behaviour therapy (12), CBTs (17), or problem-solving therapies (10).

Treatment of Major Psychiatric Disorders

Effective interventions for psychiatric disorders should reduce the risk of suicide because psychiatric disorders are almost universally found in victims of suicide. In addition, professionals within general hospital psychiatric services need to be educated about treatments that are known to be effective in reducing the risk of suicide. Currently, 2 examples stand out: clozapine for use with individuals with schizophrenia at high risk for suicide (26) and lithium as maintenance therapy for patients with bipolar affective disorder at risk for suicide (33).

Discharge From Hospital

Patients discharged from hospital form one of the highest risk groups for suicide, yet few interventions have been studied or put in place to reduce this risk. Patients with a history of suicidal behaviour should be assessed 24 to 48 hours before discharge to determine and document that the acute risk of suicide has been mitigated. New resources need to be acquired to develop and test interventions for postdischarge risk prevention. In the meantime, guidelines can be developed to ensure that patients with suicide risk are assertively followed up 7 days after discharge and that limits are placed on prescription quantities of no more than 2 weeks in high-risk patients.

Reducing Access to Means

There is evidence that education about reducing access to means should be incorporated as a part of routine psychiatric care in all patients seen in general hospital psychiatric services. Resources will be needed to develop research that will improve the impact of these educational interventions.

To conclude, evidence to date suggests that enough is known for general hospital psychiatric services to move ahead on initiatives like these to prevent suicide.

Funding and Support

Funding to support this literature review was received from the Association of General Hospital Psychiatric Services (Ontario) as part of its project to develop suicide prevention strategies in general hospitals across the province. That project is funded through the Ministry of Health and Long Term Care in Ontario.

R�sum� : Pr�vention du comportement suicidaire dans le service psychiatrique d'un h�pital g�n�ral : priorit�s de programmation

Objectif : Les services psychiatriques d'un h�pital g�n�ral sont en mesure d'offrir un leadership et de coordonner l'�laboration de programmes de pr�vention du suicide pour les personnes obtenant les services d'un h�pital g�n�ral. Nous avons men� cette analyse de la documentation pour sugg�rer des priorit�s de programmation.

M�thodes : Nous avons proc�d� � une mise � jour de l'�tude de Gunnell et Frankel qui pr�sentait les priorit�s pour Health of the Nation, la strat�gie nationale de pr�vention du suicide au Royaume-Uni. Nous avons men� une recherche, utilisant les mots cl�s pr�vention et contr�le du suicide dans toutes les �tudes et essais cliniques en anglais men�s entre le 1er janvier 1994 et le 1er mai 2004.

R�sultats : Nous avons trouv� 82 articles, dont 48 ont �t� exclus, et les 34 restants ont �t� r�partis en cat�gories de milieux de soins secondaires. Nous avons trouv� O article sur les instruments de d�pistage des risques de suicide, 16 articles sur les interventions aupr�s de personnes ayant des comportements suicidaires, 14 articles sur le traitement des troubles psychiatriques majeurs, 1 article et 1 r�sum� publi� sur le cong� d'un h�pital, et 2 articles sur la r�duction de l'acc�s aux moyens.

Conclusions : Apr�s examen de chaque cat�gorie, nous faisons plusieurs recommandations en mati�re de programme et de politiques, y compris la mise � jour r�guli�re des comp�tences d'�valuation clinique, � l'aide des lignes directrices pour l'�valuation des patients suite � une tentative de suicide, l'�valuation du risque de suicide dans les 24 � 48 heures suivant le cong� de l'h�pital, et l'int�gration dans les soins psychiatriques de routine de la formation sur la r�duction de l'acc�s aux moyens.

[Reference]

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[Author Affiliation]

Paul S Links, MD, FRCPC1, Brian Huffman, MD, FRCPC2

[Author Affiliation]

Manuscript received July 2004, revised and accepted October 2004.

1 Arthur Sommer Rolenberg Chair in Suicide Studies, Professor of Psychiatry, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario.

2 Chief of Psychiatry, North York General Hospital, Associate Professor of Psychiatry, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario.

Address for correspondence: Paul S. Links, 30 Bond Street, Rm 2-010d, Shuter Wing, Toronto, ON MSB 1W8

e-mail: paul.links@utoronto.ca