A new study found that hospitalization for suicide harmed about as many people as it helped. However, if done immediately after a suicide attempt, hospitalization might be somewhat more helpful.
On average, the researchers found that being hospitalized did not reduce a person’s risk of fatal or nonfatal suicide attempts (SA) in the next year. However, this was because hospitalization actually increased the risk of SA in about a quarter of those who experienced it (reduced risk of SA in 28.1%, but increased risk in 24%).
The researchers then separated the participants into two groups: those who were hospitalized immediately (within 24 hours) after an SA, and those who were hospitalized within a week of an SA.
They found that, on average, hospitalization didn’t help if the SA was over a day ago. However, if the SA had just happened, hospitalization was associated with a slight decrease in the likelihood of further attempts (a reduction of 7.5%).
Those who had suicidal thoughts (SI) but not an actual attempt also experienced no benefit from hospitalization, even if they were hospitalized immediately after having these thoughts.
“The findings of this study suggest that psychiatric hospitalization is associated with reduced average SA risk in the immediate aftermath of an SA but not after other recent SAs or SI only,” the researchers write.
Thus, they suggest that hospitalization is only justified for patients who have just made a suicide attempt. For patients who have suicidal thoughts or who made an attempt several days ago, hospitalization is just as likely to harm as it is to help.
The study was conducted by Harvard researcher Ronald C. Kessler and published in JAMA Psychiatry.
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Hospitalization should be our last resort. Emergency departments are ill-equipped to deal with suicidal patients. Many patients who are hospitalized for psychiatric emergencies are discharged feeling traumatized by their experience. Unfortunately, fears of legal repercussions often dictate emergency room admission for suicidal patients. Hospitals are designed to triage physical emergencies, not so much psychiatric emergencies.
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I haven’t read the article, but it does not seem to distingish trauma ED, general hospital ED or psychiatric hospital EDs. I don’t know how that works in the VA health system though…
In some hospitals there’s also liason psychiatry, that does consulting and management of “psychiatric” cases in the ED and in the rest of the hospital by psychiatrists/residents of psychiatry.
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Fears of legal reprecusions sound a poor excuse to me of the status quo.
As a dear specialist to many, famous even, used to say: “If you can’t stand the heat don’t get into the kitchen”.
And, per the words of one representative of the National Medical Arbitration Comission in my country said, she was in a easily lawsuitable speciality. And she was top notch.
As per the remedies against lawsuits, said comission for my country, don’t know how that translates in more litigious places like the US: write everything clearly in the medical records and clearly, honestly, completely explain yourself to the patient and relatives. Document everything, be considerate, respectfull and understading, in too short form.
I would add to that: write it in the clinical record so that almost anyone with little aid can understand what you did was correct, by the book, with evidence, solidly behind ANY decision that could have a negative impact.
Patients, relatives, judges, lawyers, district attorneys, journalists, etc., read those records. Nowadays they are not exclusive material of the medical literatti. A good medical job many times cannot be shown outside a medical record: it is the card of presentation of the practitioner when things go wrong.
And then there is malpractice insurance that many times makes it impossible to get or cover the harms done by bad practice. So, less problematic even.
Then there is where I started: why work when one cannot do what’s best for the patients?. That is the reason the health care system was developed in the first place, not to provide income or ego boosts for practitioners, that is a tool, not an end.
Feeling unsafe in one’s work is a signal one is doing something wrong, or should be working somewhere else, or in something else. After all practitioners through their lobby groups can influence legislation to “feel” safer.
Why aren’t they doing that in psychiatric stuff?. They are in some places, apparently, there are recent MIA articles of peer support, but that is wrong, that removes responsability not liability, at least, IMO.
If said “scared”practitioners would be in a position to advice a patient about the patient’s unsafe working environment might recommend them to look for another job, even another profession, at least sometimes. They do if there was physical risk, wouldn’t they?.
Sounds not part of the practitioners role, but, the good ol’ doc, or to a colleague, might not have seen it that way, specially if there was trust. Particularly if said worker thinks himself or IS above average in intellectual, moral, etc., capacities and abilities. Can be retrained, so to speak.
If some practitioners can’t retrain to do better or something else, then, clearly that is not a problem of medical practice.
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Don’t take it out on the patients. They didn’t design the system. They didn’t introduce the medical model and claim that mental illness is biologically based and the result of chemical imbalances.
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I think hospitalization probably helps significantly if it’s voluntary and harms significantly if it’s not. The fact that these researchers don’t control for coercion seems very intentional to me. I also see it quite often in studies of “involuntarily” treated people designed to look mixed to positive.
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Not entirely correct.
What the review says, if I am understanding it correctly is that ALL people with suicidal ideation are more likely to be harmed by hospitalization, voluntary or involuntary.
I can speculate voluntary might be better in suicide attempts within 24hrs, but the fact the researchers did not report it might indicate, might suggest, they didn’t find it made a difference, not necessarily true, but reasonable inference given positive findings are the stuff to be reported. There are incentives to own a big find, even if contrary to the profession, sometimes, I am guessing after all.
And the VA might have find usefull that piece of information: whether voluntary vs involuntary made a difference. They might complain and refuse to work with said researchers if they find it and didn’t report it. Again, I am guessing.
People with suicidal attempts can benefit ONLY if hospitalized or assesed in the ED within 24hrs of said attempt, as per the review, if I understand correctly.
A 4% difference, very small… and only studied for a year after hospitalization, the increased suicide risk by hospitalization lasts apparently, if I am remembering correctly DECADES, so longer term that 4% might turn to zero or negative as in suicidal ideation. But that’s how medicine saves lives most of the time, whether that works for POPULATIONS is another matter that will take longer than a one year retrospective study.
In the aggregate EVEN that 4% at 1 yr, might decrease sligthly life expectancy of the population, and therefore could be/would be harmfull for the population. But I am speculating, I am not advocating/recommending either way.
Reads loco I bet, but there is evidence for harm after 24hrs of a SA or for just suicidal ideation.
The researchers might have picked a sweet spot to meassure ANY positive outcome for suicide hospitalization, like a plateau of benefit, after all. Does happen, specially in psychiatric research. Robert Whitaker* has shown that for benzos for anxiety, I think, a cut off graph when anxiety scores increased with continued benzos treatment above, I think the original anxiety scores.
So, the door to benefit from hospitalization when suicidal, loosely, is very narrow, apparently: within 24hrs after an actual attempt for individuals.
And probably obfuscated by the use, increase, adding or modification of psychiatric medications.
The benefit could be MORE if hospitalized without psychiatric medications within 24hrs of a suicide attempt.
The suspicion comes to me, at least, from the instability in the depression scale ratings within 4 weeks after starting an antidepressant, very evident in a graph presented by Robert Whitaker* in one of his recent, a few months ago, reassesment of the STAR*D trials.
In that graph the aggregate scores in, I think the HAM-D looks like a steep sine wave. That speaks to me of instability, and instability and the impulsivity associated with it is a strong contributing factor not only with suicidal ideation, “what is happening to me” sort of thing, but with suicide attempts.
So, the 4% difference, the real benefit of hospitalization for suicide might be more without psychiatric medications, SSRIs, given at a minimum how mood oscilates during the first 4 weeks of starting SSRIs.
And those oscilations on said graphs are AVERAGES of more than 2,000 people, individually those oscilations might be bigger… therefore worse for individuals, than the graph would suggest.
The rest of the benefit comes apparently from avoiding ANY hospitalization in the rest of the cases, that includes voluntary AND involuntary. Unless the VA has policies that makes them ALL such or the other, or does not record it…
That would be alternative explanations of why it wasn’t distinguished. Don’t piss on the VA policies sort of thing…
* Horseplaying, nothing but gratutide and apreciation, even love without misinterpreting, don’t personally know the fellow: Buddy buddy, how are those STAR*D retractions, civil or criminal charges going? 🙂
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‘“The findings of this study suggest that psychiatric hospitalization is associated with reduced average SA risk in the immediate aftermath [within 24 hours] of an SA but not after other recent SAs or SI only,” the researchers write.’
“This particular study didn’t differentiate…”, that is such a powerfull paragraph!. Kudos!.
“This included 196,610 people (90.3% male; 59.3% white). Of those, 140,546 (71.5%) were hospitalized after presenting with SI or SA.”, that is a lot of people for a study!.
It ended at 1 yr, Hulk sad… but given how lives are saved by medicine at least acceptable, I think.
Saddly, I imagine, using a machine learning algorithm probably would repeat the creed around suicide that has not proven particularly useful, even if this study reports very interesting positive findings. In a background of harm by suicide interventions of the psychiatric kind for instance…
Apparently hospitalization, or an equivalent, without psychiatric treatment is not part of the “hypotheses” going forward. That seems severely lacking given psychiatric medications do increase suicide risk. Just speaking to a psychiatrist or having a nearby psychiatric hospital increases suicide risk, I think I’ve read…
And as pointed by the author of this great, comendable review: Peter Simmons, that might not work as hoped when hospitalization is involuntary/forced!. Some voluntary hospitalizations are actually coerced or done under threats, even the lack of choices does not make it voluntary strictly speaking…
How a 4% difference in positive versus negative outcomes of the most benefit group translates into a 16% reduction beffudles me, beyond the findings that is. I guess harm avoidance gives the extra 12%, like concealed harm by the researchers of previous? wrongdoings, by someone else of course :), is my speculation.
Funny it speaks of Emergency Department management of SA and SI. I get the feeling, possibly erroneous that it seems like throwing the hot potato into emergency physicians instead of psychiatrists.
Great review!.
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Calling voluntary an hospitalization is at least misleading when it is done with coercion, threats, incomplete or worse false information, ONLY profit motive, or no real alternative, as in lions or crucifixion…
Narratives and articles here at MIA support those scenarios, I think.
And using SSRIs in people who have had a suicide attempt might increase the mood instability seen in the graph I commented above presented by Robert Whitaker, conjecturally. That is, speculatively it could make things worse, even without hospitalization.
But I am not advocating for stop using them, and mindfull no psychiatric medication should be tapered too fast nor abruptly. What is too fast? is still an open question I think. For some there is the question if because of withdrawal, immediate or tardive can be weaned off at all.
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The idea was to help? I’m shocked.
When suffering from psych drug induced UNDIAGNOSED akathisia including suicidal ideation as a patient diagnosed with borderline following ECT at the same hospital, I never dreamed the intent of the ER was to help me. Why would I think that? I remember being mocked, denied basic necessities, told that I was hurting “the patients we *should* be helping”, told to lie on a cot in an otherwise empty room for hours, pee in a cup, take the pills.
These people are lying when they brush off the abuse that happens with “ERs are not equipped”. Then don’t bring patients there if you’re not equipped! Let them leave! Liability? Is anyone keeping tabs on the number of treatment providers who get sued because they didn’t send their patients to the ER? Where are all of these liability lawsuits that are always being used an an excuse? Mental health professionals are some of the least sue-able people on the planet in my experience.
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Could some send a link for the study info? (I’m having trouble finding it). thanks much
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https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2810865?resultClick=1
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Together with DOI: 10.1111/sltb.12560 I’d call this pretty solid evidence that coerced hospitalizations cause more suicides than they prevent.
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