OBJECTIVE: To describe the clinical circumstances in which psychiatric patients commit suicide.

DESIGN: National clinical survey. Setting: England and Wales.

Subjects: A two year sample of people who had committed suicide, in particular those who had been in contact with mental health services in the 12 months before death.

MAIN OUTCOME MEASURES: Proportion of suicides in people who had had recent contact with mental health services; proportion of suicides in inpatients; proportion of people committing suicide and timing of suicide within three months of hospital discharge; proportion receiving high priority under the care programme approach; proportion who were recently non-compliant and not attending.

RESULTS: 10 040 suicides were notified to the study between April 1996 and March 1998, of whom 2370 (24%; 95% confidence interval 23% to 24%) had had contact with mental health services in the year before death. Data were obtained on 2177, a response rate of 92%. In general these subjects had broad social and clinical needs. Alcohol and drug misuse were common. 358 (16%; 15% to 18%) were psychiatric inpatients at the time of death, 21% (17% to 25%) of whom were under special observation. Difficulties in observing patients because of ward design and nursing shortages were both reported in around a quarter of inpatient suicides. 519 (24%; 22% to 26%) suicides occurred within three months of hospital discharge, the highest number occurring in the first week after discharge. 914 (43%; 40% to 44%) were in the highest priority category for community care. 488 (26% excluding people whose compliance was unknown; 24% to 28%) were non-compliant with drug treatment while 486 (28%; 26% to 30%) community patients had lost contact with services. Most people who committed suicide were thought to have been at no or low immediate risk at the final service contact. Mental health teams believed suicide could have been prevented in 423 (22%; 20% to 24%) cases.

CONCLUSIONS: Several suicide prevention measures in mental health services are implied by these findings, including measures to improve compliance and prevent loss of contact with services. Inpatient facilities should remove structural difficulties in observing patients and fixtures that can be used in hanging. Prevention of suicide after discharge may require earlier follow up in the community. Better suicide prevention in psychiatric patients is likely to need measures to improve the safety of mental health services as a whole, rather than specific measures for people known to be at high risk. Key messages Around a quarter of people who commit suicide have been in contact with mental health services in the year before death[—]over 1000 cases annually Of these cases, 16% are psychiatric inpatients and 24% have been discharged from inpatient care in the previous three months Problems of observation caused by ward design and nursing shortages are common in cases of inpatient suicide Suicide in former inpatients occurs most commonly in the week after discharge Non-compliance with treatment and loss of contact with services are common before suicide

BACKGROUND: Few controlled studies have specifically investigated aspects of mental health care in relation to suicide risk among recently discharged psychiatric patients. We aimed to identify risk factors, including variation in healthcare received, for suicide within 3 months of discharge.

METHOD: We conducted a national population-based case-control study of 238 psychiatric patients dying by suicide within 3 months of hospital discharge, matched on date of discharge to 238 living controls.

RESULTS: Forty-three per cent of suicides occurred within a month of discharge, 47% of whom died before their first follow-up appointment. The first week and the first day after discharge were particular high-risk periods. Risk factors for suicide included a history of self-harm, a primary diagnosis of affective disorder, recent last contact with services and expressing clinical symptoms at last contact with staff. Suicide cases were more likely to have initiated their own discharge and to have missed their last appointment with services. Patients who were detained for compulsory treatment at last admission, or who were subject to enhanced levels of aftercare, were less likely to die by suicide.

CONCLUSIONS: The weeks after discharge from psychiatric care represent a critical period for suicide risk. Measures that could reduce risk include intensive and early community follow-up. Assessment of risk should include established risk factors as well as current mental state and there should be clear follow-up procedures for those who have self-discharged. Recent detention under the Mental Health Act and current use of enhanced levels of aftercare may be protective.

THE effectiveness of telephone crisis services/hotlines, examining proximal outcomes as measured by changes in callers’ crisis state from the beginning to the end of their calls to eight centers in the U.S. and intermediate outcomes within 3 weeks of their calls, was evaluated. Between March 2003 and July 2004, 1,617 crisis callers were assessed during their calls and 801 (49.5%) participated in the followup assessment. Significant decreases in callers’ crisis states and hopelessness were found during the course of the telephone session, with continuing decreases in crisis states and hopelessness in the following weeks. A majority of callers were provided with referrals and/or plans of actions for their concerns and approximately one third of those provided with mental health referrals had followed up with the referral by the time of the follow-up assessment. While crisis service staff coded these callers as nonsuicidal, at follow-up nearly 12% of them reported having suicidal thoughts either during or since their call to the center. The need to conduct suicide risk assessments with crisis callers and to identify strategies to improve referral follow-up is highlighted.

IN February 2016, the Lifeline distributed its first network wide survey since 2011. This survey sought to identify (a) promising and successful practices across the network, (b) funding trends that could facilitate Lifeline advocacy for crisis centers, and (c) priority needs for all crisis centers. A total of 134 (82%) centers responded.

In terms of follow-up, findings from this survey indicated that

91% (122 centers) provide follow up to callers
31% (41 centers) provide follow up to those discharged from hospital or ED
38% (30 centers) maintain a formal relationship w/ED
64% (86 centers) maintain an informal relationship – send and accept referrals

Findings from this survey that have been reported (in aggregate form) and distributed throughout the Lifeline network and can be found on the Lifeline Network Resource Center (ww2.networkresourcecenter.org) or by contacting Carole Ludwig, Director of Member Engagement at [email protected]

OBJECTIVE: The aim of the present study was to improve the health care of people repeatedly admitted to private hospitals.

METHOD: An open trial in which frequent utilizers were offered telephone case management over a 12 month period, was conducted.

RESULTS: An average of 24 phone calls were made to the 99 who remained in the programme for the 12 months. Psychological distress declined significantly over the 12 months, and the number of days in hospital was reduced compared to the previous year. The cost benefit ratio was 1:8.4.

CONCLUSIONS: The changes in well-being and hospitalization over the 12 months were substantial and are unlikely to be due to regression to the mean. A prospective randomized controlled trial comparing telephone case management with treatment as usual is indicated.

IN this study we evaluated the effectiveness of telephone crisis services/hotlines, examining proximal outcomes as measured by changes in callers’ suicide state from the beginning to the end of their calls to eight centers in the U.S. and again within 3 weeks of their calls. Between March 2003 and July 2004, 1,085 suicide callers were assessed during their calls and 380 (35.0%) participated in the follow-up assessment. Several key findings emerged. Seriously suicidal individuals reached out to telephone crisis services. Significant decreases in suicidality were found during the course of the telephone session, with continuing decreases in hopelessness and psychological pain in the following weeks. A caller’s intent to die at the end of the call was the most potent predictor of subsequent suicidality. The need to heighten outreach strategies and improve referrals is highlighted.

OBJECTIVE: Transitions of care are critical for individuals at risk of suicide. This study determined the return on investment (ROI) for providing postdischarge follow-up calls to patients at risk of suicide who are discharged from a hospital or an emergency department.

METHODS: Claims data were from the 2006-2011 Truven Health MarketScan Commercial Claims and Encounters Database and Multi-State Medicaid Database. Cost estimates were from eight call centers that provide postdischarge follow-up calls. The ROI was estimated for the 30 days after discharge and was calculated from a payer’s perspective (return gained for every $1 invested). One-way and probabilistic sensitivity analyses were used to examine the influence of variations of ROI model inputs.

RESULTS: Under base case assumptions, the estimated ROI was $1.76 for commercial insurance and $2.43 for Medicaid for patients discharged from a hospital and $1.70 for commercial insurance and $2.05 for Medicaid for those discharged from an emergency department. Variation in the effect size of postdischarge contacts on reducing readmission had the largest effect on the ROI, producing a range from $0 to $4.11. The ROI would be greater than $1 for both payers and across both discharge settings as long as postdischarge contact could reduce readmission by at least 13.3%. Sensitivity analyses indicated a 77% probability (commercial) and an 88% probability (Medicaid) that the ROI would be greater than $1 among hospital discharges; the probabilities among emergency department discharges were 74% (commercial) and 82% (Medicaid).

CONCLUSIONS: The study supports the business case for payers, particularly Medicaid, to invest in postdischarge follow-up calls.