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A Retrospective Study of General Hospital Patients Who Commit Suicide Shortly After Being Discharged From the Hospital
Dirk M. Dhossche, MD;
Asim Ulusarac, MD;
Wajiha Syed, MD
Arch Intern Med. 2001;161:991-994.
ABSTRACT
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Objective To assess the scope of diagnostic screening for suicide prevention in
general hospital patients.
Methods Retrospective medical record review of general hospital patients who
committed suicide and matched-control subjects who did not commit suicide
shortly after being discharged from the hospital.
Results The suicide rate was 32 per 100 000 patient-years. Eight (73%)
of 11 patients who committed suicide were diagnosed with depression, substance
use disorder, or both at their last hospital admission compared with 11 (33%)
of the controls (P<.05). Only 1 of 44 patients
(both cases and controls) was referred for psychiatric consultation.
Conclusions The suicide rate in general hospital patients was almost 3-fold higher
than in the general population. Depression and/or substance use disorders
were risk factors for suicide. Screening for those disorders may be beneficial
for suicide prevention in the general hospital population, but will likely
benefit more patients who will not commit suicide.
INTRODUCTION
PREVIOUS STUDIES have suggested that many suicides have medical and
psychiatric contacts shortly before comitting suicide.1-3
Physicians may be in a unique situation to assess suicidal behavior in patients.
More studies to identify patients at risk for suicide in different medical
settings, including the general hospital, are warranted.
An increased suicide risk has been reported in some medical conditions.4-5 Suicide in medically ill people may
be linked with comorbid psychiatric disorders, mainly depression and substance
use disorder. These disorders are important risk factors for suicide.6-7
In this retrospective medical record study, the feasibility of suicide
prevention through diagnostic screening for depression and/or substance use
disorders was examined. In agreement with previous studies, we expected to
find a higher suicide rate in general hospital patients compared with the
general population, higher rates of depression and/or substance use disorders
in patients who committed suicide than in control subjects, and underuse of
psychiatric consultation.8-9
SUBJECTS AND METHODS
DESIGN
The study population consisted of patients admitted to 3 university
hospitals in Mobile, Ala. Two are for adults and 1 is for children and women.
None have psychiatric beds. Patients are mostly indigenous and come from Mobile
County with a population of about 400 000. Some patients come from surrounding
counties for admission to specialized units (eg, the burn or transplantation
unit).
A matched case-control study was done. Cases were adult (aged  15
years) general hospital patients who were admitted to 1 of the 3 university
hospitals in Mobile, Ala, between October 31, 1995, and September 30, 1998,
and who subsequently committed suicide (in the same period). Only residents
of Mobile County were included. Persons admitted following suicide attempts
were excluded from the study as suicide attempters were considered a special
group with a higher risk of suicide than other patients. Patients who died
in the hospital following a suicide attempt were also excluded.
Controls were general hospital patients who were admitted during the
same period (October 31, 1995-September 30, 1998) and for similar reasons
but who did not commit suicide (in the same period). Three controls were selected
for each suicide case. Matching was done on age, sex, race, primary medical
diagnosis, admission period, and admission service in each university hospital.
Information was obtained through review of hospital records of the last admission.
The study was approved by the institutional review board of the University
of South Alabama, Mobile.
SUBJECTS
A complete list of suicides and uncertain deaths among Mobile County
residents was obtained from the Alabama Department of Forensic Sciences Mobile
Regional Laboratory. Cause of death was determined by the Office of the Medical
Examiner, Mobile. Admission data were obtained from the hospital administration.
Twelve cases were identified by cross-referencing databases of all suicides
(n = 134) and undetermined deaths (n = 14) and by admissions (N = 25 181)
to the university hospitals in Mobile between October 31, 1995, and September
30, 1998. Five suicides were admitted because of suicide attempts and were
excluded from further analyses. The medical record of 1 patient was lost from
the medical records department.
The study sample thus consists of 11 suicides. All suicides occurred
outside the hospital.
PROCEDURE
A systematic medical record review of cases and controls was conducted.
Hospital medical records were reviewed independently by 2 reviewers (A.U.
and W.S., both senior psychiatric residents) who were blind to the outcome
of the case (suicide or not). Discrepancies between reviewers in diagnoses
occurred in about 20% of the medical record reviews of both suicides and controls.
These were resolved in consensus meetings.
The presence and recognition of depression and/or substance use disorders
were assessed retrospectively. Three criteria were required for a diagnosis
of depression: (1) nurses' or physicians' entries of depressed mood, (2) a
medical record diagnosis of depression, and (3) the patient's use of antidepressant
medication. Substance use disorders were diagnosed if there was a medical
record diagnosis, and/or if entries documented recent substance abuse, and/or
if toxicologic results showed recent alcohol, cocaine, or cannabis use. Requests
for psychiatric consultation in cases and controls were recorded.
Death certificates of subjects who committed suicide were reviewed.
Toxicologic data were recorded from medical records at the Alabama Department
of Forensic Sciences Mobile Regional Laboratory.
STATISTICAL ANALYSES
The suicide rate in general hospital patients between October 31, 1995,
and September 30, 1998, was calculated as the probability of suicide using
the following formula: [(12/25 181) x (100 000/average time
at risk)] (ie, 1.5 years).10 The assumption
in this formula that patients entered the hospital at the same rate over the
3 years was verified.
Fisher exact tests were used to compare rates of depression and/or substance
use disorders between suicides and controls. Statistical analyses were performed
using SPSS software (Version 6.1; SPSS Inc, Chicago, Ill) for the Macintosh
personal computer (Apple, MacIntosh Inc, Cupertino, Calif). P<.05 was considered statistically significant.
RESULTS
The suicide rate was 32 per 100 000 patient-years. In Table 1, demographic, clinical, and toxicologic
information of suicides are listed. Mean age (at the time of the hospital
admission) of the patients who committed suicide was 45 (SD, 15; range 20-72).
Five younger than 45 years of age, 6 were 45 and older. There were 6 men and
5 women, 7 white and 4 black. Seven patients committed suicide within 6 months
after being in the hospital. Among suicides, 8 (73%) of 11 were diagnosed
with depression, substance use disorder, or both. Other diagnoses were schizophrenia
(n = 1), atypical psychosis (n = 1), and bipolar disorder (n = 1). These were
comorbid with depression or substance use disorder. No disorders were found
in 3 cases. Four suicides were positive for alcohol, cocaine, and/or cannabis.
All 4 were diagnosed with substance use disorder in the chart review at the
last hospital admission. Diagnostic rates of depression and substance use
disorders were compared between patients who committed suicide and controls
(data not shown). Depression and/or substance use disorders were found in
8 (73%) of 11 cases vs 11 (33%) of 33 controls (P<.05,
Fisher exact test). Substance use disorders were the most frequent diagnosis
in suicides (6 [54%] of 11 suicides). Depression was detected in 4 (36%) of
11 suicides. Two patients were diagnosed with both disorders. Findings were
similar across age, sex, and race, except that depression was found more often
in female suicides than substance abuse (40% vs 20%). Only 1 of 44 subjects
(both cases and controls) was referred for psychiatric consultation.
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Characteristics of 11 General Hospital Patients Admitted Between 1995
and 1998 Who Committed Suicide Shortly After Being Discharged From the Hospital
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COMMENT
MAIN OUTCOME MEASURES
The suicide rate in general hospital patients of 32 per 100 000
was almost 3-fold higher than in the general populations (12 per 100 000).
Most persons who committed suicide after being discharged from the hospital
had diagnosable psychiatric disorders, particularly depression and substance
use disorders, in agreement with previous suicide studies.6, 11
Rates of these disorders were higher in cases compared with controls (73%
vs 33%; P<.05, Fisher exact test). Only 1 of 44
patients (both cases and controls) was referred for psychiatric consultation.
LIMITATIONS
Only admissions to the 3 university hospitals in Mobile were considered.
No comparative data on patient populations in other hospitals in Mobile were
available. This limitation should be addressed in future studies by comparing
data from different hospital settings with (ie, those in which house staff
are usually primary care providers) and without university affiliation.
It is possible that some admissions were not recorded in the computerized
hospital databases owing to errors. Chances that a patient who later committed
suicide was omitted from the database is very small, however, owing to the
rarity of suicide. Another potential problem is the underrecording of suicides.
All verdicts of suicide and undetermined death were made following investigations
by the Alabama Department of Forensic Sciences Mobile Regional Laboratory.
Our previous and ongoing studies12 with this
department suggest to us that the number of suicides that are misclassified
as accidental or natural deaths is miniscule. In addition, none of the suicides
in this study came from the group of undetermined deaths.
The small number of suicides precluded detailed analyses. Also, the
suicide rate of 32 per 100 000 patient-years is probably an underestimate.
Some patients may have moved out of Mobile County before committing suicide
and the average follow-up time of 1.5 years is short. Results are therefore
tentative and need replication in larger and longer studies.
Another set of limitations is inherent to retrospective medical record
reviews. Rates of psychiatric disorders from a medical record review may be
underestimates owing to the varying quality of information in the medical
record entries. There is no a priori reason for more or less underreporting
in cases vs controls. This supports the higher rate of psychiatric disorders
in the patients who committed suicide compared with controls, although the
true rates may be higher than 77% and 33%.
Corroborating diagnostic evidence for the presence of substance use
disorders in some patients came from the toxicologic data at autopsy. In a
review of suicide studies,13 positive detection
of alcohol and other substances of abuse had high specificity but low sensitivity
for the diagnosis of substance use disorders. Data in this study support this
as all 4 suicides with positive levels of alcohol, cocaine, and/or cannabis
were previously diagnosed with substance use disorders (Table 1). Conversely, 2 of 6 patients with substance use disorders
had a negative toxicology screen.
The fact that only 1 of 44 patients was referred for psychiatric consultation
suggests underuse of this service, which agrees with the findings reported
in other reports.8 This is congruent with the
notion that psychiatric conditions are often missed in medical patients.9
IMPLICATIONS FOR SUICIDE PREVENTION
The elevated suicide rate in general hospital patients supports the
appropriateness of suicide prevention as a separate focus in this setting.
Depression and/or substance use disorders were risk factors for suicide, as
in other populations. A first step would be to improve early recognition and
treatment of these common disorders. Findings emphasize the importance of
continued efforts to educate hospital physicians about diagnoses, management,
and referral of patients with depression15
and substance use disorders.15
About one third of the controls were also diagnosed as having depression
and/or substance use disorder. The matched design of this study may have elevated
these rates. Controls were matched on primary medical conditions that may
be linked to depression and/or substance use disorders. Previous studies,
however, have also found high comorbidity rates (21%-51%) of depression and
substance use disorders in medical patients.9, 15
The relatively high rate of these disorders in controls reduces the possibility
of accurate prediction of patients who will commit suicide greatly as large
number of people at risk who will not commit suicide (ie, false-positive results)
will be identified.16-18
Some authors19-20 suggest
that global improvements in mental health provisions and delivery rather than
specific measures, often targeted at high-risk groups, will be necessary to
reduce suicide rates further. We believe the data in this study support this
view. Unfortunately, the challenge for health care in the United States and
in any country may then be enormous.21 Alternatively,
future research may uncover risk factors that are specific enough to guide
targeted preventions.
AUTHOR INFORMATION
Accepted for publication September 14, 2000.
We thank Charles L. Rich, MD, of the Department of Psychiatry, University
of South Alabama College of Medicine, Mobile, and Leroy Riddick, MD, of the
Alabama Department of Forensic Sciences Mobile Regional Laboratory for support.
Corresponding author: Dirk M. Dhossche, MD, Reinpadstraat 98, Bus
12, 3600 Genk, Belgium (e-mail: dr6340451{at}pol.net).
From the Department of Psychiatry, University of South Alabama College
of Medicine, Mobile. Dr Dhossche is now with Sophia Children's Hospital, Rotterdam,
the Netherlands.
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THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
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