A Fundamental Gap in Suicide Prevention: Aftercare Post Discharge from Psychiatric Hospitalization for Suicide Ideation and Attempt Sophia G. Schmidt Advisor:

A Fundamental Gap in Suicide Prevention: Aftercare Post Discharge from Psychiatric Hospitalization for Suicide Ideation and Attempt

Sophia G. SchmidtAdvisor: Dr. Holly C. WilcoxJHSPH CapstoneAugust 8, 2011

Presentation Outline

Scenario Methods Magnitude Background Conceptual framework Discussion Gaps and Limitations Conclusion

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Scenario

Imagine… Being hospitalized

having seriously considered or attempted suicide

Having a psychiatric disorder at the same time

Being discharged from the psychiatric hospital only 7 days after ideation or attempt

Would you be fully recuperated?

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Literature Review Methods

Population: Patients post discharge from short-term hospitalizations after suicide events

Methods: 26 studies from the published literature Analyzed for:

Problem causes and determinants Epidemiology Prevalence Public Health Relevance Prevention Intervention 4

Suicide Magnitude in the United States

11th leading cause of death in people over the age of 10 (2006)

Age-adjusted mortality rate of 11.27 per 100,000 (2007)

Suicide kills almost twice as many as homicide (2007)

Significant cause of Years of Life Lost (2007)

Economic costs are estimated to be $11.8 billion in lost income (2002) not including medical expenses or decreased productivity of suicide ideators or of grieving family and friends.

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Suicide Prevention Timeline Part 1

Over the past century, treatment has shifted from secure hospital environments to less secure community care

Over the past 50 years, the US mortality rate from suicide (not age-adjusted) has barely changed

1950s,1960s: Treated medically and sent home

1958: Los Angeles Suicide Prevention Center opens

1964: Working Conference on Suicide Prevention in Copenhagen said that suicide would be controlled with a “persistent and well-considered campaign against it”

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Suicide Prevention Timeline Part 2

1966: Center for Studies of Suicide Prevention established by US Government at NIMH (Now the Suicide Research Consortium)

1999: Surgeon General’s Call to Action on Suicide was published

2000s: 2001: DHHS publishes the National Strategy for

Suicide Prevention 2002: IOM report titled, “Reducing Suicide: A

National Imperative” Healthy People 2010 Healthy People 2020

In the past two decades, significant progress has been made on suicide prevention

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Cognitive Model of Suicidal Behavior Part 1

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Cognitive Model of Suicidal Behavior Part 2

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Primary risk factors for suicide post discharge

Major risk factors for suicide: Previous suicide attempt Current suicide ideation Psychiatric disorder

Other fundamental contributing factors to suicide post discharge include: Returning to an unsupportive environment Being placed on an activating/agitating new

medication Having the energy to complete the previously

considered suicide

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Other Contributing risk factors

Impulsivity Premature discharge Self-discharge Longer notations in medical charts during

hospitalization Reduction of support and supervision Reduction in care prior to the suicide

event Shame Reaction or Stigma Living alone Socially isolated Lack social support Life Stress and the inability to cope 11

Psychiatric risk factor

90% of suicide deaths were individuals suffering from psychiatric disorders. Affective disorders

are most common in suicide deaths

Important to note that most people suffering from psychiatric disorders never attempt suicide

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Release from hospital risk factor

Patients recently released from a psychiatric hospital are at high risk for suicide

Suicide post-discharge is hard to predict. It has been variably estimated that post-

discharge suicide is most likely within: A few days First 28 days First 3 months First 4 years

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Aftercare is a complex phenomenon

Continuity of Care is very important Prevention

Prior to discharge Discharge coordinators and planning Diagnosis and stabilization Education (for everyone involved) Assessment of risk factors

During the discharge period Assessment of post-discharge risk

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Aftercare is a complex phenomenon, cont.

Prevention, cont. Following discharge

Day hospital/partial hospitalization Psychotherapy Medication management Close follow-up Connection with services Engagement in community “Green Card” with emergency

contacts Outpatient Commitment

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Gaps and Limitations

Gaps in existing literature: Additional studies on various related topics Study effectiveness of health services

Limitations Statistics limitations: death reporting Magnitude limitation: counting suicide attempts Study limitations:

Generalizability of studies completed in different countries

Retrospective case notes not designed for study

Non-retrospective studies have few subjects Not possible to study “no treatment” group

ethically High possibility of death during studies 16

Conclusion

Suicide post-discharge from a short-term psychiatric hospitalization is a serious public health problem.

Although prevention and intervention relating to education, support, and clinical care have improved in the past two decades, there is still more research required to fill the gaps.

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Questions?

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