511277
2013
APY0010.1177/1039856213511277Australasian PsychiatryLarge et al.
AP
Nosocomial suicide Matthew Large Mental Health Services, The Prince of Wales Hospital, Randwick, NSW,
Australasian Psychiatry 0(0) 1–4 © The Royal Australian and New Zealand College of Psychiatrists 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856213511277 apy.sagepub.com
and; School of Psychiatry, University of New South Wales, Kensington, NSW, Australia
Christopher Ryan Centre for Values, Ethics and the Law in Medicine, University of Sydney, Discipline of Psychiatry, University of Sydney, Sydney, NSW, and; Department of Psychiatry, Westmead Hospital, Westmead, NSW Australia
Gerard Walsh Mental Health Services, The Prince of Wales Hospital, Randwick, NSW, Australia Jane Stein-Parbury Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia Martyn Patfield School of Rural Health, Sydney University Medical School, Australia
Abstract Objective and Method: To consider the possibility that adverse aspects of psychiatric hospitalisation may precipitate suicide contributing significantly to the increased rate of suicide among inpatients, given little has been published about this. Results and Conclusions: It is likely that psychiatric hospitalisation itself contributes to some inpatient suicides. This has significant implications for the delivery of inpatient psychiatric care. Keywords: suicide, hospitalisation, nosocomial, inpatient, psychiatric hospital
T
he rate of suicide among psychiatric inpatients is many times that of the general population. A recent Danish study found that psychiatric inpatients had a suicide rate of 860 per 100,000 patients per year – 72 times higher than the Danish national suicide rate.1 An earlier 2006 British study recorded a suicide rate of between 536 and 650 annually per 100,000 occupied beds between 1997 and 20032 and another study of five New York state psychiatric hospitals reported rates of suicide of between 200 and 920 suicides per 100,000 per year.3 Wolfersdorf and associates systematically examined the literature on the incidence of suicide among psychiatric inpatients in studies published between 1903 and 1987. The median figure in their review was one suicide per 500 admissions.4 Recent studies of inpatient suicide tell much the same story, with suicides occurring on average every 113,5 276,6 400,7 501,8 700,9 13001 admissions. It is usually assumed that the relationship between psychiatric inpatient status and an increased likelihood of suicide is not causal, but is a spurious association brought about by underlying factors that result in both suicide and psychiatric hospitalisation. This assumption is understandable. People who are admitted to acute psychiatry wards suffer from a range of significant psychological, social and medical problems that are known to be associated with an increased risk of suicide in the general population. Obviously, inpatients are likely to suffer from a severe mental illness.10 They are also likely
to have significant medical problems11 and problems with substance use.12 Admitted patients often face major social disadvantages, such as unemployment,13 violent victimisation14 and stigma.15 Hospitalisations can be precipitated by relationship breakdowns, interpersonal violence or legal difficulties.16 Perceived suicide risk and ongoing suicide plans after a suicide attempt are very common reasons for a psychiatric hospitalisation.17,18 Since the people being admitted to hospital have numerous features associated with an increased risk for suicide in the general population, it is often assumed that the high rate of suicide among inpatients is entirely due to corralling such people together, coupled with an acknowledged inability to prevent some suicides even in the inpatient environment. If this assumption were true, it would imply that all that need be done to decrease the rate of inpatient suicide is to improve protection against inpatient suicide. However, even if a combination of a spurious association and a failure to prevent inpatient suicide accounts for some, or even most, of the increased incidence of suicide among inpatients, there is no reason to assume that it accounts for all of this increase. There might be factors associated with inpatient psychiatric Correspondence: Matthew Large, The Kiloh Centre, The Prince of Wales Hospital, Barker Street, Randwick, NSW, 2031, Australia. Email
[email protected]
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care itself that independently contribute to the increased incidence of suicide among inpatients. Here, we refer to suicides attributable to those factors as ‘nosocomial suicides’.
Nosocomial suicides In general medicine, the risks to patient safety associated with hospitalisation itself have a long history. In 1795 Alexander Gordon noted that midwives and doctors were ‘the means of carrying’ puerperal fever from one patient to another and urged staff to wash carefully between patients.19,20 More modern examples include infections associated with intravenous access,21 surgical accidents22 and complications due to errors in the prescription and administration of medications.23 In each of these examples, factors associated with the hospitalisation itself impact adversely on the patient and increase the likelihood of morbidity and mortality. The possibility that an admission to a psychiatric ward itself increases the likelihood of some patients committing suicide has received surprisingly little attention. In 1941 Woolley and Eichert noted that, while increased hospital security against patient ‘escape’ might prevent suicides, there should also be ‘a recognition that too great a restriction of a person’s activities for the purpose of preventing suicide or escape may also increase the patient’s discomfort as to add to the urgency of his attempts’.24 Since that time however, the view that some elements of clinical care and ward design may actually be increasing suicide risk has rarely been considered.25 The lack of attention to nosocomial suicide is surprising given that psychiatric hospitalisation is frequently described as an adverse experience. Patients often find the admission process humiliating26 and fear that psychiatric hospitalisation will be stigmatising.27 Inpatients, both voluntary and involuntary, often believe themselves to have been coerced into hospital.28 Patients treated in locked wards sometimes describe ‘being trapped in a situation where they had to endure being controlled’.29 Psychiatric units can be frightening places, where verbal aggression and violence may be observed or personally experienced.30,31 The experience of being hospitalised can be frightening, demoralising and demeaning or induce feelings of abandonment, oppression and heightened vulnerability.32,33 Surely for some of these patients, the protective benefits are outweighed by the additional ‘stress’ of hospitalisation, adding to an already present suicide ‘diathesis’. 34 The negative thoughts and emotions likely to be associated with such adverse experiences cross diagnostic boundaries and are known to be associated with more severe suicide attempts.35 Moreover, the results of a recent meta-analysis suggested that symptoms, such as worthlessness, hopelessness, anxiety and depression, which might be exacerbated by a psychiatric admission, are specifically associated with the suicide of inpatients.36
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This analysis concludes that it is likely that the increase in suicide among psychiatric inpatients is a result of at least two factors. Part, and possibly most, of the increase is accounted for by the fact that the people admitted to hospital are those people most likely to attempt suicide – these are the spuriously associated suicides that can be tackled by further efforts to prevent inpatient suicide. However, some of the increase must be due to nosocomial suicide. These are people who commit suicide as inpatients but would not have taken their own lives if they remained at home. Nosocomial suicides occur among already vulnerable patients, where the suicide is precipitated by negative thoughts or emotions caused by factors associated with the inpatient admission itself. It is not possible to determine the proportion of inpatient suicides that are nosocomial, but we cannot assume that it is small. If we assume that all inpatients are equally successful at evading attempts to prevent inpatient suicide, regardless of the precipitant of their suicide, then it would require as few as 1 in 1000 of all admitted patients to commit suicide because of factors associated with inpatient care for nosocomial suicides to account for half of all inpatient suicides. Experienced inpatient psychiatrists will easily recall patients who have been profoundly traumatised by a psychiatric admission. In the context of such recollections, it will seem more than plausible that 1 in 1000 admitted patients might be driven to suicide by processes related to being in hospital.
The implications of the recognition of nosocomial suicide The recognition that some, perhaps a significant number, of inpatient suicides are nosocomial should have a profound impact on inpatient psychiatric services. Inpatient units should adopt measures that are known to frustrate efforts at self-destruction, but are unlikely to increase nosocomial suicide. Manoeuvres such as minimising ligature points for hanging and removing access to poisons and means of suffocation have been associated with a reduction in the rate of inpatient suicide,37–39 but are unlikely to adversely affect the ward milieu or to increase the negative cognitions and emotions that might be associated with nosocomial suicide. There should be more research into the incidence and causes of nosocomial suicide, as distinct from inpatient suicide generally. It may be possible, for example, to make estimates of the rates of nosocomial suicide by comparing the rates of all-cause inpatient suicide in wards with similar populations and the same environmental suicide prevention strategies, but different ward milieu. This will require a valid and reliable means of measuring a ward’s therapeutic atmosphere.40 Other research efforts might gain insights into the precipitants of nosocomial suicide through qualitative work aimed at better understanding patients’ experiences of admission,
Large et al.
especially those patients who survive an attempt on their own lives.
success.46 However, these proven measures have not been universally adopted. They must be.
It is likely that a number of measures currently instituted with the aim of reducing the incidence of inpatient suicide might actually increase the likelihood of nosocomial suicide. One-to-one nursing observation, for example, is widely used as suicide prevention strategy, but lacks an evidence base18,41 and is often experienced as extremely intrusive. The efficacy of closed or locked wards as a suicide prevention technique is also unknown, although it is known that at least some patients find the experience of admission to a locked ward distressing.42,43 Explicit recognition of the reality of nosocomial suicide should rekindle research programmes aimed at optimising the inpatient environment, an area once considered as primary to therapeutic efforts, which has ‘almost disappeared’ from professional discourse in acute psychiatric care.32
Last year, the Schizophrenia Commission released a report recommending that only units that patients would recommend to family and friends should be seen as ‘good enough’.47,48 It is likely that the proportion of patients that would make such a recommendation is likely to be inversely related to the portion of inpatient suicides that are nosocomial. Inpatient units should be benchmarked by their performance on the ‘family and friends test’.
Clinicians and administrators must adopt a more mature attitude to risk; one informed by the mathematical realities of predicting low base rate events and driven by the desire to foster the patient’s recovery. Recent years have seen the widespread introduction of ‘risk assessment tools’ to inpatient wards. These are usually instituted with the aim of determining what level of observation and what restrictions individual inpatients should be subjected to. While it will always be sensible to tailor aspects of a patient’s management to an ongoing assessment of their overall clinical state and needs, risk assessment has no utility on inpatient wards and their use leads to the arbitrary allocation of resources and unhelpful restrictions of individual freedoms.44 Psychiatrists are increasingly preoccupied with naïve notions of the medico-legal consequences of not conducting ‘risk assessments’, so much so that a recent study found that some UK psychiatrists ‘had become cautious about sending home patients who had voiced suicidal thoughts even though that patient may improve more quickly in their home environment…’.45 An explicit recognition of the reality of nosocomial suicide must stand as a counter to admitting a patient unless inpatient treatment is manifestly the patient’s best option. Mental health legislation that allows compulsory treatment on the basis of perceived likelihood of harm, rather than the presence or absence of decision-making capacity, reinforces the inappropriate emphasis on risk in clinical decisions. Such legislation is inconsistent with recovery principles and the United Nations Convention on the Rights of Person’s Disabilities and should be reformed. Finally, since it is reasonable to hypothesise that nosocomial suicide is often caused by elements in the inpatient environment that are perceived as punitive or oppressive, clinicians and administrators must take more seriously efforts to minimise or remove such elements. Recent years have seen considerable advances in measures to decrease the use of seclusion and restraint in inpatient units, accompanied by published reports of
Conclusion The suicide rate of inpatients is many times that of the general population and a significant proportion of these suicides may be nosocomial – causally related to factors associated with psychiatric admission itself. While we must continue efforts to prevent inpatient suicide, these must be balanced against their effect on ward milieu. We must strive to better understand the causes and incidence of nosocomial suicide, but meantime develop a more mature attitude to risk and significantly improve the ward environment for our most vulnerable inpatients. Disclosure Dr Large has received speaker’s fees from Astra-Zeneca and has appeared as an expert witness in cases considering inpatient suicides. Dr Ryan has appeared as an expert witness in cases considering inpatient suicides.
References 1. Madsen T, Agerbo E, Mortensen PB, et al. Predictors of psychiatric inpatient suicide: a national prospective register-based study. J Clin Psychiatry 2012; 73: 144–151. 2. Kapur N, Hunt IM, Webb R, et al. Suicide in psychiatric in-patients in England, 1997 to 2003. Psychol Med 2006; 36: 1485–1492. 3. Gale SW, Mesnikoff A, Fine J, et al. A study of suicide in state mental hospitals in New York City. Psychiatr Q 1980; 52: 201–213. 4. Wolfersdorf M, Keller F, Schmidt-Michel PO, et al. Are hospital suicides on the increase? A survey of reports on hospital suicides in the psychiatric literature of the 19th and 20th century. Soc Psychiatry Psychiatr Epidemiol 1988; 23: 207–216. 5. Krupinski M, Fischer A, Grohmann R, et al. Risk factors for suicides of inpatients with depressive psychoses. Eur Arch Psychiatry Clin Neurosci 1998; 248: 141–147. 6. Krupinski M, Fischer A, Grohmann R, et al. Schizophrenic psychoses and suicide in the clinic. Risk factors, psychopharmacologic treatment. Nervenarzt 2000; 71: 906–911. 7. Dong JY, Ho TP and Kan CK. A case-control study of 92 cases of in-patient suicides. J Affect Disord 2005; 87: 91–99. 8. Neuner T, Schmid R, Wolfersdorf M, et al. Predicting inpatient suicides and suicide attempts by using clinical routine data? Gen Hosp Psychiatry 2008; 30: 324–330. 9. Spiessl H, Hubner-Liebermann B and Cording C. Suicidal behaviour of psychiatric inpatients. Acta Psychiatr Scand 2002; 106: 134–138. 10. Narrow WE, Regier DA, Rae DS, et al. Use of services by persons with mental and addictive disorders. Findings from the National Institute of Mental Epidemiologic Catchment Area Program. Arch Gen Psychiaty 1993; 50: 95–107. 11. Reeves RR, Parker JD, Loveless P, et al. Unrecognised physical illness prompting psychiatric admission. Ann Clin Psychiatry 2010; 22: 180–185. 12. Dickey B and Azeni H. Persons with dual diagnoses of substance abuse and major mental illness: their excess costs of psychiatric care. Am J Public Health 1996; 86: 973–977.
3
Australasian Psychiatry 0(0) 13. Kammerling RM and O’Connor S. Unemployment rate as predictor of rate of psychiatric admission. BMJ 1993; 307: 1536.
32. Thibeault CA, Trudeau K, d’Entremont M, et al. Understanding the milieu experiences of patients on an acute inpatient psychiatric unit. Arch Psychiatr Nurs 2010; 24: 216–226.
14. Walsh E, Moran P, Scott C, et al. Prevalence of violent victimisation in severe mental illness. Br J Psychiat 2003; 183: 233–238.
33. Lovell K. User satisfaction with in-patient mental health services. J Psychiatr Ment Health Nurs 1995; 2: 143–150.
15. Rüsch N, Angermeyer MC and Corrigan PW. Mental illness stigma: concepts, consequences, and initiatives to reduce stigma. Eur Psychiatry 2005; 20: 529–539.
34. Mann JJ, Waternaux C, Haas GL, et al. Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry 1999; 156: 181–189.
16. Mgutshini T. Risk factors for psychiatric re-hospitalization: an exploration. Int J Ment Health Nurs 2010; 19: 257–267.
35. Hall RC, Platt DE and Hall RC. Suicide risk assessment: a review of risk factors for suicide in 100 patients who made severe suicide attempts. Evaluation of suicide risk in a time of managed care. Psychosomatics 1999; 40: 18–27.
17. Miret M, Nuevo R, Morant C, et al. The role of suicide risk in the decision for psychiatric hospitalization after a suicide attempt. Crisis 2011; 32: 65–73. 18. Bowers L, Whittington R, Nolan P, et al. Relationship between service ecology, special observation and self-harm during acute in-patient care: City-128 study. Br J Psychiat 2008; 193: 395–401. 19. Gordon A. A treatise on the epidemic of puerperal fever of Aberdeen. London: GG & J Robinson, 1795. 20. Dunn PM. Dr Alexander Gordon (1752–99) and contagious puerperal fever. Arch Dis Child Fetal and Neonatal Ed 1998; 78: F232–F233. 21. Reunes S, Rombaut V, Vogelaers D, et al. Risk factors and mortality for nosocomial bloodstream infections in elderly patients. Eur J Intern Med 2011; 22: e39–e44. 22. Alnaib M, Al Samaraee A and Bhattacharya V. The WHO surgical safety checklist. J Perioper Pract 2012; 22: 289–292. 23. Manias E. Detection of medication-related problems in hospital practice: a review. Br J Clin Pharmacol 2013; 76: 7–20. 24. Woolley LF and Eichert AH. Notes on the problems of suicide and escape. Am J Psychiatry 1941; 98: 110–118. 25. Patfield M. Creeping Custodialism Australas Psychiatry 2000; 8: 370–372. 26. Svindseth MF, Dahl AA and Hatling T. Patients’ experience of humiliation in the admission process to acute psychiatric wards. Nord J Psychiatry 2007; 61: 47–53. 27. Moses T. Stigma apprehension among adolescents discharged from brief psychiatric hospitalization. J Nerv Ment Dis 2011; 199: 778–789. 28. Sheehan KA and Burns T. Perceived coercion and the therapeutic relationship: a neglected association? Psychiatr Serv 2011; 62: 471–476.
36. Large M, Smith G, Sharma S, et al. Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients. Acta Psychiatr Scand 2011; 124: 18–29. 37. Watts BV, Young-Xu Y, Mills PD, et al. Examination of the effectiveness of the mental health environment of care checklist in reducingsuicide on inpatient mental health units. Arch Gen Psychiat 2012; 69: 588–592. 38. Mills PD, Watts V, Miller S, et al. A checklist to identify inpatient suicide hazards in veterans affairs hospitals. Jt Comm J Qual Patient Saf 2010; 36: 87–93. 39. Care Quality Commission. Monitoring of the Mental Health Act in 2010/2011. London: Care Quality Commission, 2013. 40. Friis S. Measurements of the perceived ward milieu: a reevaluation of the Ward Atmosphere Scale. Acta Psychiatr Scand 1986; 73: 589–599. 41. Manna M. Effectiveness of formal observation in inpatient psychiatry in preventing adverse outcomes: the state of the science. J Psychiatr Ment Health Nurs 2010; 17: 268–273. 42. Hummelvoll JK and Severinsson EI. Imperative ideals and the strenous reality: focusing on acute psychiatry. J Psychiatr Ment Health Nurs 2001; 8:17–24. 43. Adams B. Locked doors or sentinel nurses? Psychiatr Bull R Coll Psychiatr 2000; 24: 327–328. 44. Large M, Ryan C and Nielssen O. The validity and utility of risk assessment for inpatient suicide. Australas Psychiatry 2011; 19: 507–512. 45. Linsley P and Mannion R. Risky behaviour and patient safety: a critical culturist perspective. J Health Organ Manag 2009; 23: 494–504.
29. Johansson IM, Skärsäter I and Danielson E. The meaning of care on a locked acute psychiatric ward: patients’ experiences. Nord J Psychiatry 2009; 63: 501–507.
46. Wale JB, Belkin GS and Moon R. Reducing the use of seclusion and restraint in psychiatric emergency and adult inpatient services – improving patient-centered care. Perm J 2011; 15: 57–62.
30. Cornaggia CM, Beghi M, Pavone F, et al. Aggression in psychiatry wards: a systematic review. Psychiatry Res 2011; 189: 10–20.
47. The Schizophrenia Commission. The abandoned illness. London: Rethink Mental Illness, 2012.
31. Soliman AE and Reza H. Risk factors and correlates of violence among acutely ill adult psychiatric inpatients. Psychiatr Serv 2001; 52: 75–80.
48. Kmietowicz Z. Care of people with schizophrenia suffers as too much money is spent on secure units. BMJ 2012; 345: e7712.
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