Iris Publishers - Current Trends in Clinical & Medical Sciences (CTCMS)
Adult Suicidal Behaviour of Native Psychiatric Inpatients: A Retrospective, Record-Based Study
Authored by Saeed Shoja Shafti
Markers of risk include degree of
planning, including selection of a time and place to minimize rescue or
interruption; the individual’s mental state at the time of the behaviour, with
acute agitation being especially concerning; recent discharge from inpatient
care; or recent discontinuation of a mood stabilizer such as lithium or an
antipsychotic such as clozapine in the case of schizophrenia. Approximately
25%-30% of persons who attempt suicide will go on to make more attempts.
Suicidal behaviour is seen in the context of a variety of mental disorders,
most commonly bipolar disorder, major depressive disorder, schizophrenia,
schizoaffective disorder, anxiety disorders, substance use disorders,
borderline personality disorder, antisocial personality disorder, eating
disorders, and adjustment disorders. It is rarely manifested by individuals
with no discernible pathology, unless in specific circumstances, like medical,
political, or religious conflicts [1].
According to the findings of a
study, among male psychiatric population, the absolute risk of suicide was
highest for bipolar disorder, followed by unipolar affective disorder and
schizophrenia. Among female psychiatric population, as well, the highest risk
was found among women with schizophrenia, followed by bipolar disorder [2].
According to data, approximately 5%-6% of individuals with schizophrenia die by
suicide, about 20% attempt suicide on one or more occasions, and many more have
significant suicidal ideation. Suicidal behaviour is sometimes in response to
command hallucinations to harm oneself or others. Suicide risk remains high
over the whole lifespan for males and females, although it may be especially
high for younger males with comorbid substance use. Other risk factors include
having depressive symptoms or feelings of hopelessness and being unemployed and
the risk is higher, also, in the period after a psychotic episode or hospital
discharge [3].
It is interesting that Bleuler had
drawn clinicians’ attention that the most serious of the schizophrenic symptoms
is the suicidal drive. [4]. Up to 50 percent of suicides among patients with
schizophrenia occur during the first few weeks and months after discharge from
a hospital; only a minority commit suicide while inpatients [3]. Having three
or four hospitalizations during their 20s probably undermines the social, occupational,
and sexual adjustment of possibly suicidal patients with schizophrenia.
Consequently, potential suicide victims are likely to be male, unmarried,
unemployed, socially isolated, and living alone-perhaps in a single room. After
discharge from their last hospitalization, they may experience a new adversity
or return to ongoing difficulties. As a result, they become dejected,
experience feelings of helplessness and hopelessness, reach a depressed state,
and have, and eventually act on, suicidal ideas. [5].
Abrupt discontinuation of
medication, poor treatment compliance, social isolation, and increased
expectation of good performance from others and from patients themselves, are
risk factors for suicide in schizophrenics [6]. Also, the lifetime risk of
suicide in individuals with bipolar disorder is estimated to be at least 15
times that of the general population. In fact, bipolar disorder may account for
one-quarter of all completed suicides [7]. Many believe that, in general, first
episode psychosis (FEP) is a particularly high-risk period for suicide, in
which risk elevates by 60% within a first year of treatment as compared to
later stages of illness. In this regard, longer duration of untreated
psychosis, greater symptoms of depression, and positive symptoms of psychosis
were found to increase the odds of experiencing suicidal ideation [8].
While according to some studies
depressive symptoms during the index psychotic episode and comorbidity with
stimulant abuse at baseline were relevant predictive factors for suicidal
behaviour during the first years of first affective and non-affective psychotic
episodes [9], more depressive symptoms, higher insight, and negative beliefs
about psychosis increase the risk for suicidality in FEP [10]. Impulsive behaviour
such as self-harm, as well as having a family history of severe mental disorder
or substance use, have been stated as important risk factors for suicide in FEP
[11,12]. Furthermore, low levels of cholesterol have been described in suicide
behaviour including among those individuals who have an increased tendency for
impulsivity [13,14].
While, as a kind of psychological
explanation, some scholars believe that young men in the early stages of their
treatment are seeking to find meaning for frightening, intrusive experiences
with origins which often precede psychosis, and these experiences invade
personal identity, interactions and recovery [15], some suggests that
personality characters, specifically, passive-dependent traits can be a
predictor of first suicide attempts FEP [16]. On the other hand, no general
agreement regarding higher prevalence of suicide in FEP is so far achievable.
For example, while researchers like [2,8,17,18] have stated that FEP is a
particularly high-risk period for suicide, with a risk as high as 10-60% during
the first year of treatment, other scholars like [19-22] have expected a lower
risk or stated that suicide rates are difficult to measure in FEP patients,
even in carefully defined samples. In the present study, suicides and suicide
attempts among psychiatric in-patients, during the last five years, in Razi
psychiatric hospital, as the largest national psychiatric hospital in Iran and
region, has been evaluated to assess the general profile of suicidal behaviour
among native psychiatric inpatients, comparing first admission with recurrent
admission patients, and probing any relationship between serum cholesterol
level and suicidal behaviour.
Methods
Razi psychiatric hospital in south
of capital city of Tehran, as one of the largest and oldest public psychiatric
hospitals in the Middle East, which has been established formally in 1917 and
with a capacity around 1375 active beds, had been selected as the field of
study in the present retrospective assessment. Amongst its separate existent
sections, five acute academic wards, which have been specified for admission of
first episode adult psychiatric patients, and five acute non-academic wards,
which have been specified for admission of recurrent episode adult psychiatric
patients, with a collective capacity around two hundred active beds in each
cluster (four hundreds beds, totally), had been selected for current study.
Among the aforesaid academic divisions, two wards included female inpatients,
with around eighty beds, and the remaining three wards included male
inpatients.
All non-academic wards involved
male inpatients. For valuation, all inpatients with suicidal behaviour
(successful suicide and attempted suicide, in total), during the last sixty
months, had been included in the present investigation. Besides, clinical
diagnosis was based on Diagnostic and Statistical Manual of Mental Disorders,
5th edition (DSM-5) [23]. Also, assessment of serum lipids, including
triglyceride (TG), cholesterol, low density lipoprotein (LDL) and high density
lipoprotein (HDL), which was part of routine laboratory checkups for all
patients upon admission, whether for the first time or periodically, had been
accomplished, for comparing the suicidal subjects with non-suicidal ones,
incidentally.
Discussion
Always in psychiatry, when giving information about the
diagnosis, course of illness, and treatment, the therapist should not ignore
the risk of suicide [1]. Also, there is a high proportion of young people with
first-episode psychosis who attempted suicide before their first contact with
mental health services. This finding suggests that the mortality rates
associated with psychotic disorders may be underreported because of suicide
deaths taking place before first treatment contact [24]. It should constantly
be considered that in the psychiatric hospital setting the inpatient at risk
for suicide has previously exhibited suicidal behaviour, suffers from
schizophrenia, was admitted involuntarily, and lives alone [24].
It is interesting that among persons hospitalized, the
risk of suicide was greater in 1985-1991 than in 1995-2001 for post discharge
period, particularly for patients with schizophrenia and patients with
affective disorders. Thus, not only the restructuring and downsizing of mental
health services was not associated with any increase in suicides, the risk of
suicides decreased significantly between the two time periods among several
diagnostic categories. But, while in terms of post-discharge suicides, the
downsizing of psychiatric hospitals has been a success, there is still a substantial
need for better recognition of suicidal risk among psychiatric patients [25].
According to a survey, there are 2 sharp peaks of risk
for suicide around psychiatric hospitalization, one in the first week after
admission and another in the first week after discharge; suicide risk is
significantly higher in patients who received less than the median duration of
hospital treatment; affective disorders have the strongest impact on suicide
risk in terms of its effect size and population attributable risk; and suicide
risk associated with affective and schizophrenia spectrum disorders declines
quickly after treatment and recovery, while the risk associated with substance
abuse disorders declines relatively slower [26].
The accessibility to one or more means of suicide is a
recognized factor in psychiatric institutions. The same is true for the
conditions of care: inadequate supervision, the underestimation of the risk of
suicide by teams, poor communication within the teams and the lack of intensive
care unit promote suicide risk [27]. But according to another study in FEP,
most attempts occurred when patients were treated as outpatients and were in
regular contact with the service [17]. As suicide is a relatively rare event in
psychotic disorders, general population-based prevention strategies may have
more impact in this vulnerable group as well as the wider population [28,29].
While the immediate post-discharge period is a time of
marked risk, rates of suicide remain high for many years after discharge and patients
admitted because of suicidal ideas or behaviours and those in the first months
after discharge should be a focus of concern [30]. Back to our discussion and
according to the findings of the present study, The most common principal
diagnoses among the suicide subjects were bipolar I disorder and schizophrenia,
which was similar to the findings [2], except that no gender difference
regarding prevalence of these disorders among male and female patients was
repeatable here.
But, our findings were not in complete agreement with
the conclusion of Thong JY et al., who had found only schizophrenia and
depression as the most common principal diagnoses among their suicide subjects
[31] and Roy et al., who had declared schizophrenia as the major diagnosis among
suicide victims [24]. Meanwhile other psychiatric disorders, like personality
disorders and substance abuse disorders, in addition to the diagnoses, had been
designated in the present study, as remarkable diagnoses among suicide
subjects; though fewer than the aforementioned diagnoses. The higher prevalence
of bipolar disorder in the present assessment is likewise comparable to the
outcomes of a further study regarding suicidal behaviour among Iranian
inpatient youngsters [32].
In the same way, the higher incidence of self-mutilation, as the preferred method of suicide in the present evaluation, was parallel to the said study, except than its significantly higher prevalence amongst female adolescents [33]. Also, in keeping with the results, while the annual incidences of suicidal behaviour in both groups were comparable, they were lower than assessments [11,34], and higher than approximations [35], which could be stemmed from cultural, instrumental, diagnostic and methodical differences. Also, in accordance with the outcomes of the present assessment, no significant difference was evident between the first admission and recurrent admission inpatients, totally and separately, particularly with respect to psychotic disorders.
Such an outcome is clearly incongruous with the findings [2,8,17,18] who have stated that first episode psychosis is a particularly high-risk period for suicide and first-episode psychotic disorder , in general, has seemed to be a high-risk population for suicidal behaviour during the first year of treatment. On the other hand, our findings are compatible with the stances [19-22], who have estimated a lower risk or indicated that suicide rates are difficult to measure in FEP patients, and there is relatively little specific information about the risk of suicide at illness onset or retrospectively concerning the untreated psychotic period.
Above and beyond, with respect to relationship between
serum lipids and suicidal behaviour, outcome of the present assessment was not
in harmony with the findings [13, 14], because while there was a couple of
patients with higher or lower serum level of cholesterol, triglyceride, LDL and
HD, no specific or significant pattern was evident in this regard; so, it seems
that maybe such a difference was associated more to alteration of appetite, as
a secondary phenomenon, rather than core variation of metabolism, as a primary
etiologic issue. Anyhow, disregard to outcomes of the present study and its
similarities or differences with comparable studies, elements of an inclusive
prevention policy can be grouped under five items: securing the hospital
environment, optimization of the care of the patients at suicidal risk,
training of the medical teams in the detection of the risk and in the care of
the suicidal subjects, involvement of the families in the care and
implementation of postevent procedures following a completed suicide or an
attempt [36].
Also, to reduce the number of suicide attempts among
individuals treated for FEP, psychiatric services could consider: restricting
the amount of medication prescribed per purchase; individualized suicide risk
management plans for all newly admitted patients, including those who do not
appear to be at risk; stringent reviews of inpatient psychiatric units for
potential ligature points; providing information and psycho-education for
significant others in recognition and response to suicide risk; fostering
patients’ problem solving and conflict resolution skills; and regular risk
assessment and close monitoring of patients, particularly during the high risk
period of 3 months after a suicide attempt [17]. Also, along with enhancement
of insight, coping strategies should be boosted with a goal of minimizing
depression and preventing suicidality [37].
Absence of post- discharge following program, deficiency
of documented data regarding the suicidal behaviour or its idea before
admission, allocating wards to academic and non-academic, which could impact
the quality of care, lack of female gender in the nonacademic wards for making
it more similar to the academic wards, which included an equal mixture of male
and female inpatients, were among the weaknesses of the present assessment. In
spite of remarkable findings of the current study, more methodical and
comprehensive investigations in future, with taking into account the above
shortages, can improve the quality and amendment of mental health services for
proper response to patients’ unavoidable problems
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