In-patient suicide: selection of people at risk, failure of protection and the possibility of causation
- Type :#article
- Date read: 2023-06-20
- Bibtex: @large2017
- Bibliography: Large, M. M., Chung, D. T., Davidson, M., Weiser, M., & Ryan, C. J. (2017). In-patient suicide: Selection of people at risk, failure of protection and the possibility of causation. BJPsych Open, 3(3), 102–105. https://doi.org/10.1192/bjpo.bp.116.004309
Example citation
Negative aspects of in-patient psychiatric care might be involved in causing some suicides
My notes
- They consider whether there is a causal role of in-patient care in suicide.
- They use some kind of epidemiological framework with nine criteria: strength, consistency, specificity, temporality, biological gradient or dose response, plausibility, coherence, experiment, analogy.
- So they conclude that there currently is no RCT evidence, but that there might be a causal link between some suicides and in-patient care.
- These causal factors are called nosocomial in other parts of medicine. Importantly, they do not exclude an interaction between vulnerability and the hospital-related causes.
Admission to hospital itself might play a causal role in a proportion of in-patient suicides. The safety of being in hospital with respect to suicide could be examined with a large-scale randomised controlled trial (RCT). In the absence of an RCT, the possibility of a causal role provides further impetus to calls to make care in the community more available and psychiatric hospitals more acceptable to patients.
If we do not think it is causal, we might argue for a strong selection effect. We can also argue that the psychiatric wards prevent some suicides and that differences between wards are the result of better or poorer safety practices (staffing, levels of observation, containment policies, the built environment…).
Differences between hospitals in the extent to which they cause trauma, stigma, despair and loss of social role might be an under-recognised, but important, third factor explaining the extent and variation in in-patient suicide rates.
They have the analogy of intensive somatic care. Intensive care prevents some, but not all, deaths, and there are some deaths that occur from hospital-related factors (like getting an infection while in the ICU).
Abstract
BACKGROUND: Being a current psychiatric in-patient is one of the strongest statistical risk factors for suicide. It is usually assumed that this strong association is not causal but is a result of the combination of the selection of high-risk patients for admission and the imperfect protection from suicide afforded by psychiatric wards. Logically, a third factor, which is causal, might play a role in the association. It has recently been suggested that adverse experiences in psychiatric units such as trauma, stigma and loss of social role might precipitate some in-patient suicides. AIMS: To consider whether there is a causal association between psychiatric hospitalisation and suicide. METHOD: We used the framework of Austin Bradford Hill’s criteria for assessing causality in epidemiology to consider the possibility that psychiatric hospitalisation might causally contribute to the extent and variation in in-patient suicide rates. RESULTS: The association between psychiatric hospitalisation and suicide clearly meets five of the nine Hill’s criteria (strength of association, consistency, plausibility, coherence and analogy) and partially meets three of the remaining four criteria (gradient of exposure, temporality and experimental evidence). CONCLUSIONS: Admission to hospital itself might play a causal role in a proportion of in-patient suicides. The safety of being in hospital with respect to suicide could be examined with a large-scale randomised controlled trial (RCT). In the absence of an RCT, the possibility of a causal role provides further impetus to calls to make care in the community more available and psychiatric hospitals more acceptable to patients. DECLARATION OF INTEREST: M.M.L. and C.J.R. have provided expert testimony in legal proceedings following in-patient suicide. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license. PDF: large_2017_in-patient_suicide_-_selection_of_people_at_risk,_failure_of_protection_and_the.pdf