Factors associated with involuntary mental healthcare in New South Wales, Australia.

BACKGROUND: There is uncertainty about factors associated with involuntary in-patient psychiatric care. Understanding these factors would help in reducing coercion in psychiatry. AIMS: To explore variables associated with involuntary care in the largest database of involuntary admissions published. METHOD: We identified 166 102 public mental health hospital admissions over 5 years in New South Wales, Australia. Demographic, clinical and episode-of-care variables were examined in an exploratory, multivariable logistic regression. RESULTS: A total of 54% of eligible admissions included involuntary care. The strongest associations with involuntary care were referral from the legal system (odds ratio 4.98, 95% CI 4.61-5.38), and psychosis (odds ratio 4.48, 95% CI 4.31-4.64) or organic mental disorder (odds ratio 4.40, 95% CI 3.85-5.03). There were moderately strong associations between involuntary treatment and substance use disorder (odds ratio 2.68, 95% CI 2.56-2.81) or affective disorder (odds ratio 2.06, 95% CI 1.99-2.14); comorbid cannabis and amphetamine use disorders (odds ratio 1.65, 95% CI 1.57-1.74); unmarried status (odds ratio 1.62, 95% CI 1.49-1.76) and being born in Asia (odds ratio 1.42, 95% CI 1.35-1.50), Africa or the Middle East (odds ratio 1.32, 95% CI 1.24-1.40). Involuntary care was less likely for people aged >75 years (odds ratio 0.68, 95% CI 0.62-0.74), with comorbid personality disorder (odds ratio 0.90, 95% CI 0.87-0.94) or with private health insurance (odds ratio 0.89, 95% CI 0.86-0.93). CONCLUSIONS: This research strengthens the evidence linking diagnostic, socioeconomic and cultural factors to involuntary treatment. Targeted interventions are needed to reduce involuntary admissions in disadvantaged groups.

Association between suicidal ideation and suicide: meta-analyses of odds ratios, sensitivity, specificity and positive predictive value.

BACKGROUND: The expression of suicidal ideation is considered to be an important warning sign for suicide. However, the predictive properties of suicidal ideation as a test of later suicide are unclear.AimsTo assess the strength of the association between suicidal ideation and later suicide measured by odds ratio (OR), sensitivity, specificity and positive predictive value (PPV). METHOD: We located English-language studies indexed in PubMed that reported the expression or non-expression of suicidal ideation among people who later died by suicide or did not. A random effects meta-analysis was used to assess the pooled OR, sensitivity, specificity and PPV of suicidal ideation for later suicide among groups of people from psychiatric and non-psychiatric settings. RESULTS: There was a moderately strong but highly heterogeneous association between suicidal ideation and later suicide (n = 71, OR = 3.41, 95% CI 2.59-4.49, 95% prediction interval 0.42-28.1, I2 = 89.4, Q-value = 661, d.f.(Q) = 70, P ≤0.001). Studies conducted in primary care and other non-psychiatric settings had similar pooled odds to studies of current and former psychiatric patients (OR = 3.86 v. OR = 3.23, P = 0.7). The pooled sensitivity of suicidal ideation for later suicide was 41% (95% CI 35-48) and the pooled specificity was 86% (95% CI 76-92), with high between-study heterogeneity. Studies of suicidal ideation expressed by current and former psychiatric patients had a significantly higher pooled sensitivity (46% v. 22%) and lower pooled specificity (81% v. 96%) than studies conducted in non-psychiatric settings. The PPV among non-psychiatric cohorts (0.3%, 95% CI 0.1%-0.5%) was significantly lower (Q-value = 35.6, P < 0.001) than among psychiatric samples (3.9%, 95% CI 2.2-6.6). CONCLUSIONS: Estimates of the extent of the association between suicidal ideation and later suicide are limited by unexplained between-study heterogeneity. The utility of suicidal ideation as a test for later suicide is limited by a modest sensitivity and low PPV.Declaration interestM.M.L. and C.J.R. have provided expert evidence in civil, criminal and coronial matters. I.B.H. has been a Commissioner in Australia's National Mental Health Commission since 2012. He is the Co-Director, Health and Policy at the Brain and Mind Centre (BMC) University of Sydney. The BMC operates an early-intervention youth services at Camperdown under contract to Headspace. I.B.H. has previously led community-based and pharmaceutical industry-supported (Wyeth, Eli Lily, Servier, Pfizer, AstraZeneca) projects focused on the identification and better management of anxiety and depression. He is a Board Member of Psychosis Australia Trust and a member of Veterans Mental Health Clinical Reference group. He was a member of the Medical Advisory Panel for Medibank Private until October 2017. He is the Chief Scientific Advisor to, and an equity shareholder in, InnoWell. InnoWell has been formed by the University of Sydney and PricewaterhouseCoopers to administer the $30 M Australian Government Funded Project Synergy. Project Synergy is a 3-year programme for the transformation of mental health services through the use of innovative technologies.

The role of prediction in suicide prevention.

It is widely believed that suicide prevention involves the consideration of risk and protective factors and related interventions. Preventative interventions can be classified as "universal" (targeting whole populations), "selective" (targeting higher-risk groups), and "indicated" (protecting individuals). This review explores the range of preventative measures that might be used commensurately with different types of suicide prediction. The author concludes that the best prospects for suicide prevention lie in universal prevention strategies. While risk assessments do generate some information about future suicide, suicide risk categorization results in an unacceptably high false positive rate, misses many fatalities, and therefore, is unable to usefully guide prevention strategies. The assessment of suicidal patients should focus on contemporaneous factors and the needs of the patient, rather than probabilistic notions of suicide risk.

En general, se cree que la prevención del suicidio implica la consideración de los factores de riesgo y de protección, y las intervenciones relacionadas. Las intervenciones preventivas se pueden clasificar como "universales" (dirigidas a toda la población), "selectivas" (dirigidas a grupos de mayor riesgo) e "indicadas" (protección a las personas). Esta revisión explora el rango de medidas preventivas que podrían usarse de manera acorde con los diferentes tipos de predicción de suicidio. El autor concluye que las mejores perspectivas para la prevención del suicidio se encuentran en las estrategias universales de prevención. Si bien las evaluaciones de riesgo sí aportan cierta información sobre futuros suicidios, la categorización del riesgo de suicidio genera una frecuencia, inaceptablemente alta, de falsos positivos; deja de lado muchas muertes y es, por lo tanto, inapropiada para guiar de manera útil las estrategias de prevención. La evaluación de los pacientes con tendencias suicidas debería centrarse en los factores del momento y las necesidades del paciente, más que en las nociones probabilísticas de riesgo de suicidio.

Il est largement reconnu que la prévention du suicide implique la prise en compte des facteurs de risque et de protection et des interventions qui s'y rapportent. Les interventions de prévention peuvent être "universelles" (ciblant toutes les populations), "sélectives" (ciblant des groupes à haut risque) ou "indiquées" (protégeant les individus). Cet article explore l'éventail des mesures préventives qui pourraient être utilisées proportionnellement aux différents types de pronostic de suicide. Pour l'auteur, les meilleures perspectives de prévention du suicide résident dans les stratégies universelles de prévention. Les évaluations du risque génèrent certaines informations sur le suicide à venir, mais la catégorisation du risque suicidaire entraîne un taux inacceptablement élevé de faux positifs, passe à côté de beaucoup de décès et est donc inappropriée pour guider les stratégies de prévention. L'évaluation des patients suicidaires devrait se concentrer sur des facteurs contemporains et les besoins des patients plus que sur des notions de probabilité du risque suicidaire.

Psychiatric hospitalisation and the risk of suicide.

The association between current or recent psychiatric hospitalisation and increased suicide risk is well described. This relationship is generally assumed to be due to the selection of people at increased risk of suicide for psychiatric admission and subsequent failure of protection from suicide once admitted. Here, Matthew Large and Nav Kapur debate whether or not admission to hospital also selects for vulnerability to certain harmful aspects of hospitalisation and whether the increased rate of suicide in current and recently discharged psychiatric patients is, in fact, due to psychiatric hospitalisation itself.Declaration of interestM.M.L. has provided expert testimony in legal proceedings following in-patient suicide. N.K. sits on the Department of Health (England) National Suicide Prevention Strategy Advisory group.

Suicide Rates After Discharge From Psychiatric Facilities: A Systematic Review and Meta-analysis.

Importance: High rates of suicide after psychiatric hospitalization are reported in many studies, yet the magnitude of the increases and the factors underlying them remain unclear. Objectives: To quantify the rates of suicide after discharge from psychiatric facilities and examine what moderates those rates. Data Sources: English-language, peer-reviewed publications published from January 1, 1946, to May 1, 2016, were located using MEDLINE, PsychINFO, and EMBASE with the search terms ((suicid*).ti AND (hospital or discharg* OR inpatient or in-patient OR admit*).ab and ((mortality OR outcome* OR death*) AND (psych* OR mental*)).ti AND (admit* OR admis* or hospital* OR inpatient* OR in-patient* OR discharg*).ab. Hand searching was also done. Study Selection: Studies reporting the number of suicides among patients discharged from psychiatric facilities and the number of exposed person-years and studies from which these data could be calculated. Data Extraction and Synthesis: The meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. A random-effects model was used to calculate a pooled estimate of postdischarge suicides per 100 000 person-years. Main Outcomes and Measures: The suicide rate after discharge from psychiatric facilities was the main outcome, and the association between the duration of follow-up and the year of the sampling were the main a priori moderators. Results: A total of 100 studies reported 183 patient samples (50 samples of females, 49 of males, and 84 of mixed sex; 129 of adults or unspecified patients, 20 of adolescents, 19 of older patients, and 15 from long-term or forensic discharge facilities), including a total of 17 857 suicides during 4 725 445 person-years. The pooled estimate postdischarge suicide rate was 484 suicides per 100 000 person-years (95% CI, 422-555 suicides per 100 000 person-years; prediction interval, 89-2641), with high between-sample heterogeneity (I2 = 98%). The suicide rate was highest within 3 months after discharge (1132; 95% CI, 874-1467) and among patients admitted with suicidal ideas or behaviors (2078; 95% CI, 1512-2856). Pooled suicide rates per 100 000 patients-years were 654 for studies with follow-up periods of 3 months to 1 year, 494 for studies with follow-up periods of 1 to 5 years, 366 for studies with follow-up periods of 5 to 10 years, and 277 for studies with follow-up periods longer than 10 years. Suicide rates were higher among samples collected in the periods 1995-2004 (656; 95% CI, 518-831) and 2005-2016 (672; 95% CI, 428-1055) than in earlier samples. Conclusions and Relevance: The immediate postdischarge period is a time of marked risk, but rates of suicide remain high for many years after discharge. Patients admitted because of suicidal ideas or behaviors and those in the first months after discharge should be a particular focus of concern. Previously admitted patients should be able to access long-term care and assistance.

In-patient suicide: selection of people at risk, failure of protection and the possibility of causation.

BACKGROUND: Being a current psychiatric in-patient is one of the strongest statistical risk factors for suicide. It is usually assumed that this strong association is not causal but is a result of the combination of the selection of high-risk patients for admission and the imperfect protection from suicide afforded by psychiatric wards. Logically, a third factor, which is causal, might play a role in the association. It has recently been suggested that adverse experiences in psychiatric units such as trauma, stigma and loss of social role might precipitate some in-patient suicides. AIMS: To consider whether there is a causal association between psychiatric hospitalisation and suicide. METHOD: We used the framework of Austin Bradford Hill's criteria for assessing causality in epidemiology to consider the possibility that psychiatric hospitalisation might causally contribute to the extent and variation in in-patient suicide rates. RESULTS: The association between psychiatric hospitalisation and suicide clearly meets five of the nine Hill's criteria (strength of association, consistency, plausibility, coherence and analogy) and partially meets three of the remaining four criteria (gradient of exposure, temporality and experimental evidence). CONCLUSIONS: Admission to hospital itself might play a causal role in a proportion of in-patient suicides. The safety of being in hospital with respect to suicide could be examined with a large-scale randomised controlled trial (RCT). In the absence of an RCT, the possibility of a causal role provides further impetus to calls to make care in the community more available and psychiatric hospitals more acceptable to patients. DECLARATION OF INTEREST: M.M.L. and C.J.R. have provided expert testimony in legal proceedings following in-patient suicide. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Commentary: Adverse experiences in psychiatric hospitals might be the cause of some postdischarge suicides.

In this article, the authors comment on "Postdischarge Suicide: A Psychodynamic Understanding of Subjective Experience and Its Importance in Suicide Prevention," by Schechter, Goldblatt, Ronningstam, Herbstman, and Maltsberger (Bulletin of the Menninger Clinic, 2016, volume 80, pp. 80-96). Suicide after discharge from psychiatric hospitals is an enduring and serious problem. Consideration needs to be given to the possibility that adverse experiences associated with hospitalization, experiences such as trauma, stigma, and loss of social support, might precipitate some suicides after discharge.

Self-enucleation: forget Freud and Oedipus, it's all about untreated psychosis.

Self-enucleation is a rare but serious ophthalmological and psychiatric emergency. It has traditionally been considered to be the result of psycho-sexual conflicts, including those arising from Freud's Oedipal complex and Christian religious teaching. However, an analysis of published case reports suggests that self-enucleation is a result of psychotic illnesses such as schizophrenia. Early treatment with antipsychotic medication in the case of unilateral or threatened self-enucleation might prevent some cases of blindness.