In-patient suicide

Approximately 13% of suicides by people in contact with mental health services are by current in-patients.1 Risk is particularly high in the first week of admission, when around 25% occur.2 Over a quarter of in-patients die on the ward, the majority by hanging/strangulation. 3

Rates of psychiatric in-patients who die by suicide

  • In England there are approximately 160 psychiatric in-patient suicides per year 1
  • Between 1997/98 and 2007/08 the number of in-patient suicides in England has nearly halved (47.6%), and the rate has fallen nearly one third from 2.45 to 1.68 per 100,000 bed days 4
  • >Rates have fallen in males and females, across ethnicities, and diagnoses
  • The rate of suicide by hanging/strangulation on the ward has fallen by 59%

What are the characteristics of psychiatric in-patients who die by suicide?

  • In-patient suicide is more common in those with affective disorder, previous self-harm,  a co-morbid psychiatric diagnosis, and recent adverse life events
  • Those who have been detained for treatment have a lower risk of suicide
  • Factors associated with suicide in the first week of admission include a short (<1 year) duration of illness, adverse life events, and absconding from the ward

What ligatures and ligature points do patients use in cases of hanging on the ward?

  • The most common ligature points used in hangings on the ward are doors, hooks/handles, and windows 3
  • The most common ligatures used are belts or sheets/towels
  • In the majority of ward hangings, the ligature is brought onto the ward by the patient, i.e. a personal belonging or item of clothing
  • There have been changes in the use of particular ligature points and ligatures over the past few years. For example, the use of shoelaces, doors and windows has increased whilst the use of belts, hooks/handles, and rails has decreased

Suicide after absconding from the ward  

  • A quarter of in-patient suicides occur after the patient has absconded from the ward
  • These patient suicides are more likely to be younger, unemployed, and homeless compared to in-patients on agreed leave 
  • They often have schizophrenia and a history of violence and substance misuse
  • Many have died early in the admission, been detained for treatment and refused drug treatment

Lessons for prevention?

  • Improvements to the physical ward environment may result in further reductions in in-patient suicide, not only by removing potential ligatures and ligature points, but by making the ward a less intimidating experience to newly admitted patients
  • Measures  to prevent absconding include tighter control of ward exits, and more intensive observation of patients, particularly in the first few days of admission
  • Knowledge of life events experienced before admission should be incorporated into initial risk assessments

References:

1. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Annual Report 2011.

(http://www.bbmh.manchester.ac.uk/cmhr/research/centreforsuicideprevention/nci/reports/annual_report_2011.pdf)

2. Hunt IM, Kapur N, Webb R, Robinson J, Burns J, Turnbull P, Shaw J, Appleby L (2007) Suicide in current psychiatric in-   patients: a case-control study. Psychological Medicine, 37; 831-837.

(http://www.ncbi.nlm.nih.gov/pubmed/17306045)

3. Hunt IM, Windfuhr K, Shaw J, Appleby L, Kapur N (2012) Ligature points and ligature types used by psychiatric in-patients who die by hanging: a national study. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 33: 87-94.

 (http://www.ncbi.nlm.nih.gov/pubmed/22343063)

4. Kapur N, Hunt IM, Webb R, Williams A, Windfuhr K, Shaw J, Appleby L (2012) Suicide in

psychiatric in-patients in England, 1997-2008. Psychological Medicine. Doi: 10.1017/S0033291712000864.

 (http://www.ncbi.nlm.nih.gov/pubmed/22591851)

5. Hunt IM, Windfuhr K, Swinson N, Shaw J, Appleby L, Kapur N (2010) Suicide amongst psychiatric

in-patients who abscond from the ward: a national clinical survey. BMC Psychiatry,10:14 doi: 10.1186/1471-244X-10-14.

(http://www.biomedcentral.com/1471-244X/10/14)