Inpatient suicide and self-harm attempts are two sentinel events hospitals seek to avoid. Nonetheless, each year, patients are able to commit suicide or self-harm within hospitals. While several national entities have provided guidance to reduce the risk of self-harm among inpatients, no global standard exists to address these preventable events. The objectives of this paper are to evaluate current standards of care used around the world to prevent suicide and self-harm attempts and to make practical recommendations for hospital staff to implement for a safer hospital environment. Staff training, proper environment modification, patient assessment, and other protocols can help ensure patients are cared for in a healthy and low-risk way. Therefore, hospitals should seek to have specific guidelines in place to properly care for patients who may express suicide ideation or the desire to self-harm. These guidelines should include patient assessment and follow-up measures to ensure patient care is continuous throughout hospitalizations. A true understanding of the effectiveness of programs and interventions is difficult to achieve without data and surveillance measures that provide an accurate estimate of suicide and self-harm attempts among inpatients around the world. Future research should address way to provide more accurate surveillance of these adverse events and measure the population-level effects of interventions that may benefit patients.
Patient self-harm and suicide rates during inpatient hospital stays have remained a concern for hospitals around the world, although accurate estimates are difficult to determine (Williams, Schmaltz, Castro, & Baker, 2018). The Joint Commission, a leader in hospital standardization and guidance in the United States, considers patient suicide to be a “sentinel event,” meaning prevention should be considered in terms of patient safety not as part of a natural disease course (“Comprehensive Accreditation Manual for Hospitals,” 2017). This distinction magnifies the need for hospital staff preparation to prevent these events through patient monitoring, environmental modification, and other specific actions to help improve outcomes (Williams et al., 2018). Clinical practice guidelines are developed based on research and provide guidance based on most current research for treatment providers to use with patients experiencing or at risk of disease or self-harm and suicide (Wilhelm, Korczak, Tietze, & Reddy, 2017).
Self-harm rates are often difficult to calculate and are underreported internationally (Reuter Morthorst, Soegaard, Nordentoft, & Erlangsen, 2016). Data from the United States shows that non-fatal self-harm events have increased dramatically in recent years (Matthay, Farkas, Skeem, & Ahern, 2018). A meta-analysis in the United Kingdom estimated an average of 20 per 100,000 patients per month completed self-harm in the hospital (James, Stewart, & Bowers, 2012). Patients who have self-harmed in the past are likely to repeat or to attempt suicide within five years (Carroll, Metcalfe, & Gunnell, 2014). Common means of self-harm in inpatient settings include burning, re-opening wounds, cutting, and strangulation or self-ligature (James et al., 2012).
The annual rate of inpatient suicide attempts is difficult to determine, especially since not all States require the reporting of suicide-related hospital deaths (Williams et al., 2018) and not all hospitals accurately report suicide deaths (Walsh, Sara, Ryan, & Large, 2015). A recent meta-analysis estimated the international inpatient suicide rate to be between 577 and 715 per 100,000 population, with the United States having the highest rate and Nordic countries having the lowest estimates (Walsh et al., 2015). A recent study based on data from The Joint Commission Sentinel Events Database and National Violent Death Reporting Systems data estimates the suicide rate to be between 48.5 and 64.9 per 100,000 each year, which challenged a previously accepted estimate of 1,500 incidents of suicide in hospitals annually in the United States (Williams et al., 2018). Compared to the general United States population, military veterans have experienced higher rates of inpatient suicide attempts (Watts, Shiner, Young-Xu, & Mills, 2016). Worldwide, suicide attempts in hospital settings have increased in recent years (Walsh et al., 2015). Understanding the cause of these inpatient suicide attempts and implementing protocols to help protect patients are necessary to reduce the number of these attempts.
Suicide attempts generally occur as a result of stressors from a variety of factors and the degree of suicidality can change from day to day (Betz et al., 2016). The high rates of suicide attempts in hospital settings may be related to new policies around the world requiring hospitalization when one exhibits suicide ideation (Wang & Colucci, 2017). Self-ligature was the most commonly identified method among inpatient suicide deaths in the United States, while jumping from considerable heights and drug overdose have also been reported (Williams et al., 2018). Each patient may experience a different stressors and circumstances that culminate in their suicide ideation.
Rapid yet effective screenings can help identify patients who are at risk of suicide and allow for fast treatment (Koweszko et al., 2016). Suicide prevention programs should exist in all hospitals and may also be useful for individuals hospitalized with general self-harm behaviors (Hawton et al., 2015), since self-harm is often linked with future suicide attempts (Carroll et al., 2014). Suicide and self-harm prevention programs may require educating healthcare staff and managing the hospital environment to help reduce risk (Betz et al., 2016; Navin, Kuppili, Menon, & Kattimani, 2019) or may consist of constant observation of patients considered at higher risk (Russ, 2016). This understanding of suicide risk is imperative to proper care and treatment during the hospital stay.
Knowing patient self-harm and suicide attempts are prevalent yet preventable, it is important for hospitals and other inpatient facilities to prepare to prevent and handle these situations. Therefore, the purpose of this review is to identify what suicide and self-harm prevention strategies have been effectively utilized during inpatient hospital stays around the world. These successful interventions will be evaluated for effectiveness and recommendations will be identified based on existing research to help hospitals mitigate the risk of suicide and self-harm among inpatients.
There are several risk factors associated with patient self-harm and suicide during an inpatient hospital stay. These risk factors include specific socio-demographic variables that increase risk as well as during which part of the stay are the incidents most likely to occur. Understanding these risk factors can help clinicians and hospital administrators better address this issue.
RISK FACTORS FOR SELF-HARM
Self-Harm may occur as a result of perceptions of unbearable situations, a wish to die, feelings of loss of control, or a desire to show others the level of hopelessness being experienced. Underlying trauma, rejection, loneliness, and psychiatric issues may contribute to these factors (de Beurs, Vancayseele, van Borkulo, Portzky, & van Heeringen, 2018). Additionally, living in a community with high levels of violence may increase the risk of non-fatal self-harm among members of the community, even though suicide attempts are unchanged based on this metric (Matthay et al., 2018).
Several studies from around the world have provided insight regarding risk factors for self-harm among different populations. A longitudinal study conducted in the United Kingdom showed White individuals and females were most likely to experience self-harm. However, males reported more life problems, such as relationship issues, than females. Employment and alcohol use also had significant roles in self-harm attempts (Townsend et al., 2016). Patients discharged from the emergency department following a self-harm incident may not have a mental health diagnosis or receive help in a follow-up, which can lead to future self-harm or suicide attempts (Horrocks, Price, House, & Owens, 2003) Self-harm is a risk factor for eventual suicide, as most people with suicide attempts also have previous self-harm attempts (Hawton et al., 2015). Consequently, the two conditions may have similar risk factors.
RISK FACTORS FOR SUICIDE
Numerous studies have sought to understand risk factors for suicide in the general population as well as in inpatient settings. Understanding suicide risk of patient populations is necessary for providing adequate care and mitigating the risk of suicide during inpatient stays or after being discharged (Avci, Selcuk, & Dogan, 2017). However, understanding this risk is challenging due to the diverse mix of at-risk individuals (Wilhelm et al., 2017). Diagnosis of suicidality is not enough to accurately manage and treat patients. Rather, it is important to understand patient history and current situations that may lead to a suicide attempt (Wilhelm et al., 2017).
Self-harm attempts may be able to be used to model suicide risk. One study showed that the risk of suicide for individuals who had a self-harm incident in the past year was 49 times higher than among those who had no prior self-harm attempts. This risk is especially high within the first 6 months following a self-harm attempt (Hawton et al., 2015). Thus, knowing the self-harm history of patients may help identify those who are at a higher risk of suicide.
Some sociodemographic factors have been linked to heightened suicide risk (Navin et al., 2019), including elderly populations who are hospitalized (Avci et al., 2017). As the older adult population increases, suicide incidence within this population are expected to rise, especially among those with significant stressors (Conwell, Van Orden, & Caine, 2011). The World Health Organization (WHO) recognizes that people over 70 years of age are at the highest risk of suicide, whereas individuals under the age of 15 are at the lowest risk of suicidal ideation (World Health Organization, 2014).
One Turkish study showed that among elderly patients in hospitalized settings, those at highest risk for suicide lived alone, were more likely to drink alcohol, had a history of psychiatric hospitalization, were being treated for cancer, and had weak religious beliefs (Avci et al., 2017). A study in Korea compared suicidal individuals who used community mental health services and hospitalized patients seeking mental health treatment. In the study, suicidal patients who were hospitalized were reportedly experiencing more stress and had more severe family mental health histories and prior suicidal behaviors, which may have put them at higher risk for suicide (Park et al., 2017). Additionally, this study showed that those who were hospitalized had significantly higher rates of current suicide risk than the community at large and were more likely to have recurrent major depressive episodes (Park et al., 2017).
When assessing risk for inpatient suicide exclusively, more specific risk factors have been determined. Previous suicide attempts, self-harm, family history, and severe mental disorders are risk factors for inpatient suicide (Navin et al., 2019). In the United States, there is a higher incidence of suicide attempts in psychiatric hospitals compared to general or other inpatient facilities (Williams et al., 2018). Lack of staff and resources in comparison to the number of mental health patients may also increase suicide risk (Navin et al., 2019). These risk factors help determine interventions that may be beneficial.
Specific timeframes in which suicide risk is heightened include shortly after a patient is admitted to the hospital (Navin et al., 2019). Walsh et al. found that inpatient suicide rates were inversely related to how long the patient stayed in the hospital (Walsh et al., 2015). Furthermore, within seven days after discharge, patients recently released from mental health hospital care are at increased risk of suicide (Chung et al., 2017; Riblet et al., 2017). Knowledge of these specific risk factors allow physicians and hospital staff to be on alert during times when suicide risk is highest during a stay or immediately after discharge.
In addition to these risk factors, the WHO has recognized several protective factors related to suicide, such as emotional and social well-being (World Health Organization, 2014). This may include physical activity and adequate sleep as well as close, healthy relationships. Religious beliefs or having faith in something may be protective, but may also lead to negative stigma related to suicide and mental health awareness (World Health Organization, 2014). Promoting these protective factors may reduce suicide.