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Hospitalization Following Suicide Attempt May Benefit Some, but Individualized Approach Needed
Psychiatric hospitalization may reduce the number of additional suicide attempts (SA) in the immediate aftermath of an SA, but not for other recent SAs or suicide ideation (SI) alone. Researchers published their findings from the retrospective analysis in JAMA Psychiatry.
Though suicidality now makes up approximately 1.1% of all emergency department visits in the United States and hospitalization is the accepted standard of care, there are no established risk scales to aid clinical judgement when deciding on treatment for this patient population.
“Considering the substantial costs and unclear effectiveness of psychiatric hospitalization in preventing suicidal behaviors, it is critical to find a means of targeting this intervention to the patients most likely to benefit and to avoid hospitalization in patients for whom it might be harmful,” said lead author Eric L. Ross, MD, department of psychiatry, Larner College of Medicine, University of Vermont, Burlington, and co-authors in the study introduction.
Researchers used observation data from patients with suicidality who presented to emergency departments and urgent care centers within the Veterans Health Administration to train a predictive analytics model that could estimate treatment effect of hospitalization on risk of SA, establish whether the patient population under study is heterogenous, and develop an initial “preliminary individualized treatment rule (ITR)” that indicates risk/benefit profiles for each patient.
In general, of the 196,610 visits (90.3% men; median [IQR] age, 53 [41-59] years) analyzed, 71.5% resulted in psychiatric hospitalization. The risk for subsequent SA over 12 months was 11.9% with hospitalization and 12.0% without (difference, -0.1%, 95% CI, -0.4% to 0.2%). For patients with SI only or SA in the past 2 to 7 days, hospitalization generally was not associated with subsequent SAs. In patients with SA in the past day, regardless of mental health diagnoses, hospitalization was associated with -6.9% to -9.6% risk reduction. When accounting of heterogeneity, hospitalization was associated with reduced risk of subsequent SAs in 28.1% of the population and increased risk in 24%.
The study authors then used these findings to simulate the effects of ITRs, and hypothesized that accounting for these associations via ITRs may reduce SAs by 16.0% and hospitalizations by 13.0% compared to current rates.
“Our findings have immediate clinical implications for management of suicidality in ED settings. For patients presenting in the aftermath of an SA, clinicians could reasonably consider hospitalization the default approach in that it might be expected to substantially reduce the overall risk of subsequent SAs without increasing the risk among any identifiable patient sub-set,” the authors wrote in the conclusion. “In contrast, for patients with suicidality other than in the immediate aftermath of an SA, hospitalization is not a justifiable default approach, as hospitalization is associated with an increased risk of subsequent SAs in 20.0% to 40.0% of patients and decreased risk in another 20.0% to 40.0%.”
Study authors listed 7 “noteworthy” limitations of the study, including the possibility of confounding bias, lack of direct observation of exposure and outcome, limits and errors in computing, inclusion of nonfatal SAs, limiting study to patients in the VHA system, other clinical responses as alternatives to psychiatric hospitalization, and exclusion of other reasons for psychiatric hospitalization.
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