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High-risk strategies v. universal precautions against suicide

Published online by Cambridge University Press:  02 January 2018

Matthew M. Large*
Affiliation:
University of New South Wales, Sydney, Australia. Email: [email protected]
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Abstract

Type
Columns
Copyright
Copyright © Royal College of Psychiatrists, 2012 

The recent paper by Gunnell et al Reference Gunnell, Metcalfe, While, Hawton, Ho and Appleby1 and the accompanying editorial by Pitman & Caine Reference Pitman and Caine2 clearly outline the practice and principles of a contemporary approach to suicide prevention in mental health settings. However, I do not think the policy initiative that every patient with a serious mental illness or a recent episode of self-harm should be followed up within a week of discharge is really a high-risk approach to suicide prevention. Patients who self-harm and those with serious mental illness must constitute the vast majority of people who are admitted to psychiatric hospitals and therefore this recommendation is more like a universal precaution against suicide than a targeted intervention based on a high-risk model.

In my view there are compelling reasons to doubt the usefulness of high-risk categorisation for future suicide at the point of discharge from psychiatric hospitals. It is known that discharged patients have about a 100-fold increased risk of suicide compared with the general community in their first few weeks at home. Reference Qin and Nordentoft3 However, those categorised as at high risk of suicide after discharge are only about four times more likely to take their own life than discharged patients categorised as at low risk of suicide. Reference Large, Sharma, Cannon, Ryan and Nielssen4 Hence, compared with the risk of just being a discharged patient, being at high risk or low risk is virtually meaningless.

If the English guideline for early follow-up of patients has been successful, this is almost certainly because it approximates a universal precaution against suicide and not because of the success of a high-risk approach. We need to acknowledge that all those admitted to psychiatric hospitals have a very high absolute risk of suicide and that we are unable to tell who will be safe.

References

1 Gunnell, D, Metcalfe, C, While, D, Hawton, K, Ho, D, Appleby, L, et al. Impact of national policy initiatives on fatal and non-fatal self-harm after psychiatric hospital discharge: time series analysis. Br J Psychiatry 2012; 201: 233–8.Google Scholar
2 Pitman, A, Caine, E. The role of the high-risk approach in suicide prevention. Br J Psychiatry 2012; 201: 175–7.Google Scholar
3 Qin, P, Nordentoft, M. Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry 2005; 62: 427–32.Google Scholar
4 Large, M, Sharma, S, Cannon, E, Ryan, C, Nielssen, O. Risk factors for suicide within a year of discharge from psychiatric hospital: a systematic metaanalysis. Austr N Z J Psychiatry 2011; 45: 619–28.Google Scholar
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