When faced with a patient who has had suicidal ideas or shown suicidal behaviour, a clinician has to decide whether the patient needs to be admitted to the hospital for safety reasons, or whether it is safe to treat that patient at home. Current clinical reasoning and practice is that if one is in doubt about safety-admit; hospitalization prevents suicides. However, there is absolutely no evidence that it does. In fact , there is almost no useful research about psychiatric hospitalization. This has led to such comments as ” the extent to which admission eventually results in reductions in risk or in any clinical and social benefits to the patient is largely unknown” ( National Insitute for Health Research -UK); and, ” There is a sense that hospital care is a black box , with people being admitted and discharged , but with little known about what happens to them while they are there” ( Royal College of Psychiatrists Quirk and Lelliot)
In spite of this lack of research evidence of effectiveness of hospitalization, intensive home treatment research indicates that is still necessary in about 55-60% of acutely ill patients. But, utilization of hospital for acute mental disorders is coming under increasing scrutiny and a more realistic picture of its benefits, limitations and negative effects is starting to emerge.
This report is part of that trend. It is the result of assessing all people in England and Wales, Scotland, and Northern Ireland, over four years who had committed suicide and had been in contact with mental health services in the year before death.
In summary, between 16% ( England and Wales) and 10% ( Northern Ireland) were psychiatric in-patients at the time of death. 20% of these were on close or constant observation; 25% occurred during first week of admission.
Between 23% ( England and Wales) and 30% ( Northern Ireland) died within three months of discharge from hospital; post-discharge suicides were at a peak in the first 1-2 weeks following discharge. Between 40% and 66% of post-discharge suicides occurred before the first follow up appointment.
This report has led to questioning as to whether hospital admission reduces suicide-or does it just delay it. For example, Dr Neil Brimblecombe, Director of Mental Health Nursing at the Department of Health , England states : ” It is important to recognize that admission to hospital may not , in any case , have the effect of eliminating or even reducing risk. The experience of hospital admission can be distressing and stigmatising in itself, and suicides are still relatively common in inpatient settings. Risk may simply be delayed , as suicides are also relatively common in the period immediately following the discharge from a ward. ”
national confidential inquiry suicide homicide one year contact mental health services