What is the benefit of psychiatric hospitalization after a suicide attempt?

[deleted314290]

I know this may sound obvious, but other than starting/changing meds, creating a temporary safe environment, and enrolling in or coordinating outpatient care, what benefit does inpatient hospitalization serve after a suicide attempt? I find most of the people who are post attempt either endorse relief that they weren't successful or just give me lip service about their attempt to make me go away. In the latter, what should the goals of inpatient treatment be and at what point is the patient "safe for discharge" knowing a percentage of these will go on to attempt again? Furthermore, for people with serious attempts, they usually already have 1-2+ week hospital courses in which I often have seen that by default they get sent to a psych facility once medically cleared. Once again, is there any benefit for automatic admit after a suicide attempt or is this just a CYA type of thing? I am curious to hear what other peoples experiences are and thoughts on this matter. Thank you.

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[Armadillos]

Furthermore, for people with serious attempts, they usually already have 1-2+ week hospital courses in which I often have seen that by default they get sent to a psych facility once medically cleared

While not the point of your thread I'm curious about this part about "with serious attempts they usually have 1-2week hospitalization .

Seems like in my experience only a very tiny percent of serious attempts require a 1+ week medical hospital stay (or any medical hospital stay at all). Its pretty challenging to come close enough to dying to require a week in the hospital but not actually kill yourself. Seems like what I see most often is a serious attempt interrupted or failed in some way and the person requires no medical care or someone needs to spend a night being monitored s/p overdose and then is quickly medically cleared.

 

[smalltownpsych]

It depends a lot on dx and social situation. For someone who is severely depressed, a couple of weeks might help get them to where they are able to function enough to benefit from outpatient treatment. For some patients, the time is needed to come up with alternative plans or placements or even outpatient appointments. I am booked for about a month out so the hospitals know to call for an appointment when the patient gets there. For other patients, especially kids, a brief stay shows that people are taking them seriously. The worst is when the kid tells me, "I tried it before and they just blew it off and did nothing." Translation "they don't really care about me".

 

[DD214_DOC]

It's a bit of everything you've mentioned. Partly CYA; sending a patient who just attempted suicide back home for them to commit suicide looks kinda bad in court. So, you admit them for safety and it buys time to try and change whatever modifiable risk factors they may have, arrange or provide resources and support, and try to understand what happened. It also gets the patient away from whatever intense psychosocial stressors may have precipitated an attempt. Prolonged hospitalizations on an acute unit probably shouldn't happen, becuase acute units are not meant for that. If they are that ill they should propably transition to residential.

You do what you can to help, but ultimately you cannot control other people. Some will, for whatever reasons, end their own lives. It's the unforunate outcome of some of the pathology we treat, and this idea that our goal should be, "zero suicides" is completely unrealistic. As a medical community, the way we conceptualizing mental illness/behavioral illness/whatever you want to call it now needs to change. Some of the pathology we deal with is just as terminal as other chronic illnesses.

 

[Bartelby]

In my experience there is no such thing as an "automatic admit," but when doing a safety assessment for someone who just made a real attempt to end their life the bar is pretty high to send them out. As you listed changing medications, providing temporary observation, and making sure the patient has a real outpatient plan occur, all of which can be important. You also get to take a little more time to get to know the patient, hopefully build some semblance of an alliance, and gather collateral as appropriate. None of those things sound like "CYA" to me, they sound like providing basic care that may end up being lifesaving to someone who is in crisis.

That said, if a very involved CL team has gotten to know and care for the patient over a several week stay and a full safety assessment suggests that the person does not need to be in a psychiatric hospital then discharge can be appropriate. I have occasionally been involved in such cases. Still, when you do a cost/benefit analysis the benefit of making sure you thoughtfully maximize the person's chance of recovery (or at least decrease the odds for another near-term attempt) weighed against the cost of keeping them in the hospital a bit longer after their medical stay for a serious suicide attempt tends to skew heavily in favor of keeping the patient in most instances.

To turn the question around, why would you feel inclined to arrange a fast discharge for patients who have just tried to kill themselves?

 

[hamstergang]

To turn the question around, why would you feel inclined to arrange a fast discharge for patients who have just tried to kill themselves?

I guess the important question is, does hospitalizing the patient actually impact on their suicide risk? I doubt there's a great way to study this but I'm sure some have tried. Anyone familiar with the literature?

 

[DD214_DOC]

I guess the important question is, does hospitalizing the patient actually impact on their suicide risk? I doubt there's a great way to study this but I'm sure some have tried. Anyone familiar with the literature?

It's a good question, and a quick article search didn't turn up much. I was only able to find one article looking at this question. Over a 2-year post-hospitalization follow-up, the conclusion was, "No", it didn't matter. I think this highlights an important distinction in how we assess risk. I assess and document the risk of IMMINENT self-harm and suicide. The further out you try to assess, the more useless it is. We really aren't any good at assessing imminent or short-term risk, and there's no way to assess long-term risk.

How often have you had the, "is there a such thing as rational suicide?" debate? It's a very interesting one. Why do we feel empathic towards those who suffer a poor quality of life due to chronic medical conditions and condone their decision to end their own suffering, but those who have a poor quality of life due to a chronic psychiatric condition must continue doing so despite a myriad unsuccessful treatment attempts?

 

[erg923]

I guess the important question is, does hospitalizing the patient actually impact on their suicide risk? I doubt there's a great way to study this but I'm sure some have tried. Anyone familiar with the literature?

There is. And it doesn't. Usual caveats related to the fact that we work with individuals and noy large groups, as well the tricky nature of studying suicide.

 

[WisNeuro]

The literature is not great. Suicide attempt risk looks to have two peaks, right before admission and immediately after discharge. Some data suggests people with shorter admission stays are more likely to attempt at discharge, when other factors are controlled. Suggesting that adequate assessment before discharge is important. Not sure I'd make the conclusion that it does nothing for suicide risk, though, considering the dearth of adequate literature in the area. One caveat being some studies suggesting that chronic suicide attempts in a BPD setting is perhaps best managed in outpatient settings, although I pnly know snippets of those and am not up to date on my literature in Borderline PD.

 

[smalltownpsych]

The literature is not great. Suicide attempt risk looks to have two peaks, right before admission and immediately after discharge. Some data suggests people with shorter admission stays are more likely to attempt at discharge, when other factors are controlled. Suggesting that adequate assessment before discharge is important. Not sure I'd make the conclusion that it does nothing for suicide risk, though, considering the dearth of adequate literature in the area. One caveat being some studies suggesting that chronic suicide attempts in a BPD setting is perhaps best managed in outpatient settings, although I pnly know snippets of those and am not up to date on my literature in Borderline PD.

Regarding BPD, you might be confusing attempts with ideation. The treatments I'm familiar with for BPD suggest that attempts should be dealt with through brief hospital stays (a couple of days in my mind) aimed at stabilizing mood and ensuring safety and then processed in painstaking detail or interpreted as a resistance to treatment. The ideation is often chronic with BPD and hospitalization is not indicated for that.

 

[WisNeuro]

Regarding BPD, you might be confusing attempts with ideation. The treatments I'm familiar with for BPD suggest that attempts should be dealt with through brief hospital stays aimed at stabilizing mood and ensuring safety and then processed in painstaking detail or interpreted as a resistance to treatment. The ideation is often chronic with BPD and hospitalization is not indicated for that.

Nope, I was referencing attempts. There is actually some data suggesting inpatient is not as efficacious at reduction in attempts and actually lead to worse outcomes in this population. Something from McGill seems to come to mind.

 

[Rogue Penguin]

How exactly could one ethically conduct a study on whether hospitalization makes a difference in long-term outcomes? Get acutely suicidal people to sign up for the study in the ER and then randomly select half of them to be discharged to the street???? Anyway you do it, it seems like there would be issues with selection bias. People who are assessed as needing inpatient treatment are going to be generally sicker than those who are not. And there are certainly a lot of suicidal people who seek no treatment at all. There would also be a crazy number of confounding factors that contribute to past and future suicidality. If the inpatient stay isn't making a difference, maybe it needs to be longer or more personalized. The quality of the hospital in question could also be a factor. It seems like it would be incredibly logistically difficult to get any sort of statistically significant results that you could truly use to make generalizations about suicidal patients as a population.

 

[michaelrack]

x

 

[nitemagi]

Nope, I was referencing attempts. There is actually some data suggesting inpatient is not as efficacious at reduction in attempts and actually lead to worse outcomes in this population. Something from McGill seems to come to mind.

Reinforcement for SA as a pseudo-coping strategy, to engage with further social support. I've seen it the most in the peds population and in the borderline spectrum.

How exactly could one ethically conduct a study on whether hospitalization makes a difference in long-term outcomes? Get acutely suicidal people to sign up for the study in the ER and then randomly select half of them to be discharged to the street???? Anyway you do it, it seems like there would be issues with selection bias. People who are assessed as needing inpatient treatment are going to be generally sicker than those who are not. And there are certainly a lot of suicidal people who seek no treatment at all. There would also be a crazy number of confounding factors that contribute to past and future suicidality. If the inpatient stay isn't making a difference, maybe it needs to be longer or more personalized. The quality of the hospital in question could also be a factor. It seems like it would be incredibly logistically difficult to get any sort of statistically significant results that you could truly use to make generalizations about suicidal patients as a population.

It's probably not prospective data.

 

[Amygdarya]

Yes, based on a quick overview, most suicide studies seem to be retrospective. But there are a lot of confounders to the outcomes measured, as Rogue Penguin pointed out. There is nothing like a prospective randomised study to establish a cause-effect relationship, which, as discussed above, would be unethical to perform. The rest is merely food for thought/fuel for discussion.

 

[smalltownpsych]

Nope, I was referencing attempts. There is actually some data suggesting inpatient is not as efficacious at reduction in attempts and actually lead to worse outcomes in this population. Something from McGill seems to come to mind.

If that study is referring to longer term stays like even two weeks, then that fits with what I understood, as well. Inpatient treatment has never been demonstrated to be an effective intervention for BPD to the best of my knowledge. I just find it hard to believe that when someone attempts suicide that it is a good idea to let them go as soon as they are medically stable. I tend to at least have them stay overnight, we talk about it in the morning and then get outpatient treatment going. Interestingly enough, everyone else at the hospital wants to send them to inpatient treatment and the families often feel the same way. I can't get people to come to me for the 2x a week for the couple of months that it requires to deal with the initial phase of treatment, but the two to 4 weeks in a relatively stress free environment makes everyone think they are cured and completely surprised when patient sees me once or twice for a follow-up after discharge and then attempts suicide a couple months later. Of course, they also find the new magic combination of medications to deal with their "bipolar".

 

[WisNeuro]

It's complicated issue, and the research is pretty split between BPD, schizophrenia, and major depression. It's hard to generalize one from the other, as they are very different disorders and the SA/SI from each is a pretty unique beast. My comments were more about how people were flippantly stating that there is no benefit. The research does not suggest that. It doesn't suggest the opposite either. If we're going to be data-based, we have to be data based each way.

 

[Ceke2002]

I can only speak for myself, obviously, but I don't think being hospitalised for a week or more after my attempt would have really been the right thing for me, unless the hospitalisation consisted of getting a proper treatment plan in place - that didn't involve overreacting Psychiatrists attempting to diagnose me as Schizophrenic and trying to have me admitted to the state mental hospital, which only served to make me reluctant to engage in any further treatment with them, because holy misdiagnosis batman! Granted at the time I probably should have sought medical attention directly after surviving the attempt, but I wasn't aware of the risks post surviving a suicidal hanging attempt at that time, and I was way too embarrassed/mortified to admit what I'd done (luckily I got away with just a sore throat, some difficulty speaking because of hoarseness, and the need to wear a scarf to hide the ligature mark for a couple of weeks - but considering the rope only broke some time after I'd lost consciousness I was probably pretty fortunate in that respect). So anyway for me it would have depended entirely on *why* I was being kept in hospital for a week or more, just admitting me for the sake of admitting me (CYA, safety concerns, whatever else), to my mind at least would have been fairly pointless unless there was also going to be follow up outpatient care put in place as well.

 

[FlowRate]

While not the point of your thread I'm curious about this part about "with serious attempts they usually have 1-2week hospitalization .

Seems like in my experience only a very tiny percent of serious attempts require a 1+ week medical hospital stay (or any medical hospital stay at all). Its pretty challenging to come close enough to dying to require a week in the hospital but not actually kill yourself. Seems like what I see most often is a serious attempt interrupted or failed in some way and the person requires no medical care or someone needs to spend a night being monitored s/p overdose and then is quickly medically cleared.

Bilateral traumatic amputation after jumping from a highway overpass was the last one I saw. Patient had a super eerie emotional detachment from the event, wavering between frank denial one day and recognition of the attempt but with a completely positive affect the next, telling us how it made him realize that he wants to go back to school, pursue some sort of healthcare career or something -- he previously had a low-skill job that required use of his legs, but didn't ever say that explicitly. Sort of a spin on a flight into health. Was fascinating -- saw him on the medical floor as psych CL until he went inpatient.