To our knowledge, this is the first study to assess the acute changes in suicidality during the first few days of psychiatric hospitalization. The results indicated that hospitalization was associated with rapid reduction of suicidality over three days, with percentages of patients at high suicide risk dropping from 66.0–39.7% and moderate sized reductions in a continuous measure of suicidality.
This study examined changes in suicidality during the first three days after admission before the effects of psychotropic medications and psychotherapeutic interventions are likely to have their effects, although short term sedatives may relieve anxiety and improve sleep over even such a short period of time. Previous studies have demonstrated hospital-related reductions in repeat self-harm within 12 months albeit much smaller. Among the children and adolescents hospitalized for self-destructive behavior repeated rate of such behavior were 17.7% among those who had been hospitalized compared to 21.5% among those who had or not, a small but significant effect [14].
Several mechanisms may be involved in these effects. Hospitalization provides increased security for the patients through continuous care, close observation, and limiting access to lethal implements. Patients in the current study showed significant changes in hopelessness and depression, suggesting that the non-specific support of hospitalization allowed patients to regain optimism, perhaps through the support of their families and hospital staff. Increased social connections with other hospitalized patients may also have decreased their social isolation and exposure to external stressors [15].
Previous studies [16] have shown that individual factors are poor predictors of future suicidal behavior although it is widely believed that focusing on modifiable predictors, such as family/social stressors may contribute to the development of risk reduction methods [17]. In the current study, only employment was associated with reducing likelihood of remaining at high risk over a very short period of time but it is unclear how this observation might support the development of short-term interventions. In addition, although studies have suggested that psychotic illnesses are associated with increased and more prolonged suicide risk[18], it is notable that the diagnosis of schizophrenia was not associated with more severe risk in this study.
Patients at acute risk for suicide, however, are often sent home with a referral to their general practitioner, or with no referral at all [19]. For example, data from Ireland [20] indicate that among patients presenting with self-harm full behavior(n = 12,588), 24% were admitted to a general medical ward and only 7% were admitted for psychiatric inpatient treatment with fewer than 1% of refusing admissions. A majority of patients (56%) were discharged from the emergency department, 21% without any referral at all [20]. Hospitalization is costly, especially so for the uninsured, and open beds are not infrequently unavailable[5]. As a result, hospitalization is commonly avoided for non-clinical reasons, in part because the acute benefits of hospitalization have not been studied to our knowledge.
This study has several limitations. Firstly, the lack of a randomly assigned non-hospitalized control group limits the interpretation of efficacy. However, it would have likely been deemed unethical to base this study on a randomized design. The effects likely reflect a combination of the non-specific effects of being in a safe supportive environment, away from precipitating stressors, and some degree of regression to the mean of a regularly fluctuating mood. Secondly, as we did not have data on medications initiated prior to the hospitalization, we cannot exclude their potential impact. Further the sample was based on retrospective data from a single medical center, and its generalizability is unknown.
Nevertheless, in an era when efforts are being made to reduce use of hospital treatment in China as elsewhere, the statistically significant and substantial reductions in suicidality over three days following hospitalization are notable and deserve consideration as pressure increases to reduce the use of costly inpatient care.