Risk for premature death, suicide significantly higher following psychiatric discharge
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Key takeaways:
- Rates of premature death and suicide were significantly higher after psychiatric discharge compared with rates in the general population.
- Premature death was linked to cognitive and alcohol-related disorders.
Individuals discharged from psychiatric inpatient care appeared vulnerable to premature death and suicidal behavior, according to a study published in JAMA Network Open.
“There is a need for representative research on serious adverse outcomes following discharge from psychiatric hospitalization,” Philippe Mortier, PhD, of the Health Services Research Group at Hospital del Mar Research Institute in Barcelona, Spain, and colleagues wrote.
To compare rates of premature death, suicide and nonlethal intentional self-harm after psychiatric discharge with rates in the general population, Mortier and colleagues conducted a retrospective cohort study of 49,108 patients (mean age, 44.2 years; 52.6% male) from Catalonia, Spain, who had psychiatric hospitalizations between 2014 and 2018 when aged at least 10 years.
Researchers defined premature death as death by any cause before age 70 years and suicide as death resulting from intentional self-harm. Further, they identified nonlethal intentional self-harm using electronic health record and self-harm case register data.
Mortier and colleagues investigated the associations of these outcomes with independent variables at the index psychiatric hospitalization, including sex, age, socioeconomic status, intentional self-harm at admission and during follow-up, 15 mental disorder categories, duration of the index hospitalization and number of previous psychiatric admissions.
Additionally, the researchers calculated standardized mortality ratios (SMRs) to compare rates of premature death and suicide between the cohort and the general population.
Overall, 2,260 (4.6%) patients died prematurely during follow-up, equating to SMRs for premature death of 7.5 (95% CI, 7.2-7.9) overall, 7.7 (95% CI, 7.2-8.3) for females and 7.5 (95% CI, 7.1-7.8) for males.
This risk for premature death that was nearly eight times higher in this population compared with the general public “underscores the necessity for further studies distinguishing between premature and general mortality in discharged individuals, which is crucial for providing evidence to prevent avoidable deaths and address health disparities in this vulnerable population,” the researchers wrote.
Of these deaths, 437 (0.9%) died by suicide, for SMRs of 32.9 (95% CI, 29.9-36) overall, 47.6 (95% CI, 40.2-54.9) for females and 27.9 (95% CI, 24.6-31.2) for males.
In fully adjusted sex-stratified hazard models, cognitive disorders (females: adjusted HR = 2.89; 95% CI, 2.24-3.74; males: aHR = 2.59; 95% CI, 2.17-3.08) and alcohol-related disorders (females: aHR = 1.41; 95% CI, 1.18-1.7; males: aHR = 1.22; 95% CI, 1.09-1.37) increased risk for premature death following psychiatric discharge.
The researchers noted that “this finding emphasizes the importance of targeted prevention interventions for patients with alcohol use disorders, including improved detection and treatment efforts for neoplasms, infectious diseases, diabetes, circulatory system diseases and respiratory diseases.”
In addition, the researchers found suicide risk increased with intentional self-harm following discharge for both females (aHR = 2.83; 95% CI, 1.97-4.05) and males (aHR = 3.29; 95% CI, 2.47- 4.4), with depressive disorders (aHR = 2.13; 95% CI, 1.52-2.97) and adjustment disorders (aHR = 1.94; 95% CI, 1.32-2.83) among males, and with bipolar disorder among females (aHR = 1.94; 95% CI, 1.21-3.09).
Further, intentional self-harm following discharge was associated with index admissions for intentional self-harm (females: aHR = 1.95; 95% CI, 1.73-2.21; males: aHR = 2.62; 95% CI, 2.2-3.13), adjustment disorders (females: aHR = 1.48; 95% CI, 1.33-1.65; males: aHR = 1.99; 95% CI, 1.74-2.27), anxiety disorders (females: aHR = 1.24; 95% CI, 1.1-1.39; males: aHR = 1.36; 95% CI, 1.18-1.58), depressive disorders (females: aHR = 1.54; 95% CI, 1.4-1.69; males: aHR = 1.8; 95% CI, 1.58-2.04) and personality disorders (females: aHR = 1.59; 95% CI, 1.46-1.73; males: aHR = 1.43; 95% CI, 1.28-1.6).
The researchers noted limitations of the study included the exclusion of health information of private health care providers and the use of EHR data, which may be prone to misclassification and low registration by medical professionals. They also did not investigate repetition of self-harm following discharge, nor did they have access to the specific causes of premature death in the cohort.
“Future studies should also investigate the associations of mental disorder comorbidity, time-varying effects of post-discharge repeat self-harm and post-discharge repeat hospitalizations with serious post-discharge adverse outcomes,” the researchers wrote.
In a related editorial, Morten Hesse, PhD, and Julie Elizabeth Brummer, PhD, pointed out that the risk for suicide was notably different for males and females.
The results showed that “fewer males than females report suicidal ideation, while males, on average, make more serious suicide attempts, a phenomenon that has long been known as the gender paradox in suicidal behavior.”
Hesse and Brummer also added that the study “is a valuable addition to the current research on suicide risk in hospitalized populations.”
“By conducting more studies of this kind in a variety of settings, we can gain clinically useful knowledge that can be used to develop integrated mental and physical health treatment plans and improve patient outcomes,” they wrote.