Emergency Psychiatry

Suicide after involuntary psychiatric care: a nationwide cohort study in Sweden
Leoni Grossmann, Fred Johansson, Seena Fazel, Ralf Kuja-Halkola, Björn Bråstad, David Mataix-Cols, Lorena Fernández de la Cruz, Bo Runeson, Paul Lichtenstein, Zheng Chang, Henrik Larsson, Isabell Brikell, Brian D'Onofrio, Ronnie Pingel, Christian Rück, John Wallert

Abstract:

Background: Little is known about the risk of suicide in individuals treated against their will in involuntary psychiatric care (IPC). This population-based study provides a first comprehensive description of suicide among individuals who experienced IPC.

Methods: We studied all individuals discharged from IPC in Sweden from 2010 through 2020. Clinical and sociodemographic characteristics are reported followed by suicide risk for the complete IPC population and stratified by sex, age, IPC history, and diagnostic category. Crude and adjusted relative risks compared to all individuals discharged from psychiatric in- and outpatient care and the general population were estimated using Poisson regression. Suicide methods, seasonal trends, and geographical variance are also reported.

Findings: We identified 72 275 patients treated in IPC with a total of 134 514 inpatient care episodes (mean age = 44·8 years, 37 462 [51·8%] males). Of these, 2104 (2·9%) died by suicide over a median follow-up time of 4·4 years (IQR: 1⋅8-7⋅5). Suicide decedents were younger, more often male, single, diagnosed with personality and substance use disorders, and had a history of self-harm and IPC, compared to those who did not die by suicide. The absolute risk (crude incidence rate (IR) per 100 000 person-years) for all IPC patients was highest closest to discharge (IR_1month = 2941 [2538, 3408]) and decreased thereafter (IR_5years = 738 [705, 773]). Suicide risk in IPC patients was elevated relative to psychiatric inpatients (crude IR ratio (IRR)_5years = 1·57 [1·48, 1·65]), psychiatric outpatients (IRR_5years = 3·77 [3·58, 3·97]), and the general population (IRR_5years = 55·52 [52·65, 58·54]).

Interpretation: We found substantial risk differences in distinct subgroups of IPC patients and an excess suicide risk among IPC patients compared to other clinical populations. These findings warrant further investigation as they could inform clinicians and policy makers regarding potential risk stratification, monitoring, and care. Preventing suicides after IPC should be a priority.

Annotation

The finding: This Swedish population-based register study examined outcomes of 72,275 patients receiving involuntary psychiatric care (IPC) from 2010-2020. Among IPC patients, 2.9% ultimately died by suicide, and one suicide was recorded for every 64 IPC discharges. Among those receiving IPC, patients who were more likely to die by suicide were also diagnosed with a substance use disorder, had a history of intentional self-harm, or had a separate episode of IPC. The investigators found that the number of IPC episodes increased the risk of future suicide in a dose dependent manner. Young adults, and young men in particular, constituted the highest risk demographic. The suicide adjusted incidence rate ratio for patients receiving IPC was 3.78 times that of psychiatric outpatients and 184.75 times that of the general population at one month. Five years after IPC, the risk of suicide was 1.55 times that of voluntary inpatients, 4.43 times that of outpatients, and 51.04 times that of the general population.

Strength and weaknesses: The Swedish Compulsory Psychiatric Care Act requires that IPC may only be given if the patient suffers a severe mental disorder, has an indispensable need for psychiatric care, and refuses care or is unable to provide consent. The authors elaborate: the risk of harm to self or others is only a consideration. These criteria are distinct from many US states and indicates that the patient population undergoing involuntary care in Sweden may be of a different acuity than those experiencing similar levels of care in the US. Another aspect of generalizability includes the lack of mention of firearm deaths in the study, which likely reflects international differences in ease of access to firearms and ownership rates; the methods of suicide are likely to be slightly different based on local regulations.

Additionally, register studies require accurate coding and diagnosis; given the stigma of substance use and personality disorders, as well as the lack of clarity surrounding accidental deaths or suicidal behavior, these results may misrepresent true suicide risks. Finally, inpatient psychiatric bed availability impacts access to care and the clinical trajectory of at-risk psychiatric patients; the results of any retrospective study attempting to correlate level of care with suicidal behavior or suicide completion are inherently impacted by bed availability.

Relevance: This article refines the CL and emergency psychiatrist’s risk assessment to include a temporal understanding of the highest risk period of suicide post-discharge: one month. Additionally, the study results provide helpful reminders of the comorbidities that increase the subsequent risk of suicide, namely substance use disorders, and demand that substance use be considered in safety planning and coordination of care.

Interestingly, the results suggest that the ratio of male:female suicide completion among IPC patients is less than that in the general population, potentially indicating that as acuity increases the “male” risk factor becomes less potent.

Finally, while those with organic psychotic disorders and schizophrenia spectrum disorders had the highest rates of survival after IPC, readers should understand this in the context of a relatively well-defined evidence base supporting first episode psychosis clinics, long acting injectable medications, and programs providing intensive case management and treatment; that is to say, these individuals may not be low risk but, perhaps, that the structures for treatment are more advanced for these particular disorders.