Psychiatr Serv 50:1491-1493, November 1999 1999 American Psychiatric Association Brief Report

Assessment of Suicide Risk 24 Hours After Psychiatric Hospital Admission

Mark J. Russ, M. ., !odd "ashdan, B.A., Simcha Pollack, Ph. . and Senada Ba#mako$ic%"acila, M. . ABS!RA&! Of 9 !atients a"mitte" to a hos!ita# beca$se of s$ici"e ris%, 30 &44 !ercent' (ere com!#ete#y free of s$ici"a# i"eation )4 ho$rs after a"mission* Scores on the Sca#e for S$ici"e +"eation at the time of a"mission "istin,$ishe" !atients (ho contin$e" to have s$ici"a# i"eation )4 ho$rs #ater &the s$staine"-i"eation ,ro$!' from those (ho "i" not &the transient-i"eation ,ro$!'* Patients in the transient ,ro$! (ere more #i%e#y than those in the s$staine" ,ro$! to have ma"e a s$ici"e attem!t "$rin, the (ee% before a"mission* At a"mission !atients in the s$staine" ,ro$! (ere more #i%e#y to have !sychotic sym!toms an" to re!ort a fami#y history of !sychiatric i##ness* '(!R) *&!')(S -#inica# .$",ment informe" by an assessment of ris% factors is the mainstay of "ecision ma%in, (hen c#inicians are face" (ith the !ros!ect of hos!ita#i/in, a !otentia##y s$ici"a# !atient* 0is% factors associate" (ith s$ici"a# behavior ten" to have a hi,h "e,ree of sensitivity1that is, they are ab#e to i"entify in"ivi"$a#s (ho #ater commit s$ici"e &1'* 2o(ever, they have #o( s!ecificity, or #itt#e abi#ity to e3c#$"e in"ivi"$a#s (ho "o not #ater commit s$ici"e &1'* 4h$s their !re"ictive !o(er is serio$s#y com!romise"* 5iven the $ncertainty of !re"ictin, s$ici"a# behavior, c#inicians ten" to favor hos!ita#i/in, the !atient, "es!ite the #ac% of em!irica# "ata s$,,estin, that ac$te hos!ita#i/ation is effective in re"$cin, s$ici"e ris% &)'* +t has been o$r c#inica# im!ression that a s$bstantia# !ortion of !atients a"mitte" to o$r hos!ita# beca$se they are "eeme" to be at si,nificant ris% for s$ici"e are no #on,er .$",e" to be ac$te#y s$ici"a# the ne3t "ay* 4he !$r!ose of this st$"y (as to systematica##y investi,ate this c#inica# im!ression* +f it (as confirme", (e so$,ht to "etermine (hether se#ecte" "emo,ra!hic an" c#inica# variab#es co$#" "istin,$ish the transient#y s$ici"a# ,ro$! &ca##e" the transient ,ro$!' from the remainin, !atients (ho contin$e" to be ac$te#y s$ici"a# )4 ho$rs after a"mission &ca##e" the s$staine" ,ro$!'* M+!H) S S$b.ects consiste" of ) men an" 43 (omen !atients a"mitte" to the 2i##si"e 2os!ita#6on, +s#an" 7e(ish 8e"ica# -enter (ith s$ici"e ris% s$fficient to (arrant hos!ita#i/ation, as .$",e" by the a"mittin, !hysician* A## b$t fo$r !atients (ere a"mitte" on a vo#$ntary basis* Patients (ere e3c#$"e" if they #ac%e" ca!acity to ,ive (ritten informe" consent for !artici!ation* No !atients (ere e3c#$"e" base" on "ia,nosis* A## 9 !atients (ere assesse" a!!ro3imate#y )4 ho$rs after a"mission to the in!atient service* Nineteen of these !atients (ere a#so intervie(e" at the time of a"mission beca$se research staff (ere avai#ab#e* 4he intervie( !rotoco# (as the same for the s$bsam!#e of 19 !atients assesse" at the time of a"mission9 the st$"y instr$ments (ere a"ministere" t(ice to these !atients*

:ata ,athere" "$rin, the intervie( inc#$"e" "emo,ra!hic information an" history re#ate" to !sychiatric i##ness an" treatment* Severa# instr$ments (ere a"ministere", inc#$"in, the Sca#e for S$ici"e +"eation &SS+' &3', the ;ec% :e!ression +nventory &;:+' &4', the ;ec% 2o!e#essness Sca#e &;2S' &5', the ;rief Psychiatric 0atin, Sca#e &;P0S' & ', an" the 6ife <vents +nventory &='* A""itiona# "ata co##ecte" consiste" of DSM-IV a3is + an" a3is ++ "ia,noses obtaine" from the a"mission me"ica# recor"9 ser$m cho#estero#, beca$se of the observe" association bet(een #o( ser$m cho#estero# an" s$ici"a# behavior &>'9 an" #en,th of stay on the in!atient service* Patients (ere c#assifie" as bein, transient#y s$ici"a# if at the )4-ho$r fo##o(-$! a score of /ero (as obtaine" for the first five items on the SS+, in"icatin, a tota# absence of s$ici"a# i"eation* Patients (ho re!orte" any s$ici"a# i"eation at the )4-ho$r fo##o(-$! as meas$re" by the SS+ (ere c#assifie" as bein, in the s$staine" ,ro$!* -om!arisons bet(een the transient ,ro$! an" the s$staine" ,ro$! (ere con"$cte" $sin, chi s?$are ana#yses for noncontin$o$s variab#es an" in"e!en"ent t tests an" re!eate"meas$res ana#ysis of variance &ANO@A' for contin$o$s variab#es* R+S*,!S Of the 9 !atients a"mitte" beca$se of s$ici"e ris%, 30 &44 !ercent' (ere fo$n" to be com!#ete#y free of s$ici"a# i"eation )4 ho$rs after a"mission* 4he meanAS: a,e of the !atients in this ,ro$! (as 3>A1> years* 4he other 39 !atients (ere c#assifie" as bein, in the s$staine" ,ro$! at )4 ho$rs* 4heir meanAS: a,e (as 3>A1) years* No si,nificant "ifferences bet(een the transient an" s$staine" ,ro$!s (ere fo$n" in ,en"er, race, re#i,ion, marita# stat$s, chi#"ren $n"er 1> years o#" at home, #ivin, a#one, em!#oyment stat$s, mana,e" care stat$s, #eve# of e"$cation, a,e, an" n$mber of #ife stressors an" their !erceive" severity* 4he transient an" s$staine" ,ro$!s "i" not "iffer in the !ro!ortion of !atients (ith a3is + affective "isor"ers &>3 !ercent an" >= !ercent, res!ective#y', a3is ++ "isor"ers &30 !ercent an" 3 !ercent', s$bstance ab$se history &10 !ercent an" )> !ercent', an" fami#y history of s$ici"e &3= !ercent an" 3 !ercent'* +n a""ition, no "ifferences (ere fo$n" bet(een the transient an" s$staine" ,ro$!s in the meanAS: n$mber of #ifetime s$ici"e attem!ts &1*=A 1*9 an" 3*1A5*1 attem!ts, res!ective#y', n$mber of !revio$s !sychiatric hos!ita#i/ations &3A5*> an" 5*1A=*4', ser$m cho#estero# &195A40 an" )01A 51 m,B"6', an" #en,th of stay &1 A 14*) an" 15*5A11*5 "ays'* Patients in the transient ,ro$! (ere si,nificant#y more #i%e#y than those in the s$staine" ,ro$! to have ma"e a s$ici"e attem!t in the (ee% before a"mission &50 !ercent vers$s )3
) !ercent9 C5*4), "fC1, !C*0)'* Patients in the s$staine" ,ro$! (ere si,nificant#y more #i%e#y to have a fami#y history of !sychiatric i##ness than !atients in the s$staine" ,ro$!

&4= !ercent vers$s > !ercent9 on a"mission &43 !ercent vers$s

C *) , "fC), !C*04' an" to have !sychotic sym!toms

)

!ercent9

C3*= , "fC1, !C*05'*

Psycho#o,ica# meas$res (ere ana#y/e" se!arate#y for !atients eva#$ate" )4 ho$rs after a"mission on#y an" for those eva#$ate" both at a"mission an" )4 ho$rs #ater* Not s$r!risin,#y, as sho(n in 4ab#e 1, !atients in the transient ,ro$! ha" #o(er scores on a## sca#es, in"icatin, si,nificant#y #ess severe sym!toms an" #ess im!airment at a"mission

an" at )4-ho$r fo##o(-$! than !atients in the s$staine" ,ro$!* As 4ab#e 1 sho(s, a si,nificant ,ro$!-by-time interaction (as evi"ent in scores on the SS+, ;:+, ;2S, an" ;P0S for the 19 !atients assesse" on t(o occasions9 a## scores im!rove" )4 ho$rs after a"mission for the !atients in the transient ,ro$!* -ie. this 4ab#e 1* Scores on the Sca#e for S$ici"e +"eation &SS+', ;ec% ta/le0 :e!ression +nventory &;:+', ;ec% 2o!e#essness Sca#e &;2S', an" ;rief Din this Psychiatric 0atin, Sca#e &;P0S' of !atients intervie(e" at hos!ita# (in"o(E a"mission an" )4 ho$rs #ater, by (hether they (ere free of s$ici"a# Din a ne( i"eation )4 ho$rs &transient ,ro$!' or not free &s$staine" ,ro$!' 1 (in"o(E

8oreover, !atientsF scores at a"mission on the tota# SS+ an" on its first five items !re"icte" (hether they (o$#" be c#assifie" at )4 ho$rs as bein, transient#y s$ici"a# or in the s$staine" ,ro$!* At a"mission, the SS+ scores of !atients in the transient ,ro$! (ere si,nificant#y #o(er than those of !atients in the s$staine" ,ro$!, both the tota# SS+ score &tC)* ), "fC1)*4, !C *0))' an" the score on the first five SS+ items &tC)*14, "fC1=, !C*04='* 'S&*SS')(S A( &)(&,*S')(S Gsin, the criterion for Hs$ici"e non-i"eatorsH !ro!ose" by ;ec% an" associates &3', (e confirme" o$r c#inica# im!ression that many !atients a"mitte" beca$se of s$ici"e ris% no #on,er !resente" an imminent s$ici"e ris% )4 ho$rs after a"mission* 8any !ossib#e e3!#anations can be offere" for this observation, ran,in, from the !ossibi#ity that !atients initia##y !resente" an e3a,,erate" s$ici"e ris% an" (ere ina!!ro!riate#y a"mitte" to the vie( that !atients ,en$ine#y benefite" from the safety, res!ite, an" s$!!ort of hos!ita#i/ation* 4hese !re#iminary fin"in,s s$,,est "irections for f$t$re investi,ation* SS+ scores at the time of a"mission (ere associate" (ith membershi! in the transient an" s$staine" ,ro$!s )4 ho$rs after a"mission1#o(er scores (ere associate" (ith transient s$ici"a# i"eation, (hi#e hi,her scores (ere associate" (ith s$staine" i"eation* Ie $ne3!ecte"#y fo$n" that !atients (ho recent#y ma"e a s$ici"e attem!t (ere #ess #i%e#y to have s$ici"a# i"eation )4 ho$rs after a"mission* A s$ici"e attem!t may "ischar,e "ys!horic affect an" ame#iorate s$ici"a# i"eation* A simi#ar i"ea has been !ro!ose" (ith res!ect to se#f-in.$rio$s behavior of !atients (ith bor"er#ine !ersona#ity "isor"er &9'* Ie are not s$,,estin, any chan,es in the c$rrent c#inica# !ractice of caref$# in"ivi"$a#i/e" assessment of s$ici"e ris% an" nee" for hos!ita#i/ation* 4his e3!#oratory st$"y is #imite" by its sma## sam!#e si/e, #ar,e n$mber of variab#es, absence of str$ct$re" "ia,nostic assessment, an" hi,h !ercenta,e of vo#$ntary !atients* +n a""ition, the st$"y "i" not e3amine the "ecision-ma%in, characteristics of !hysicians* 4hese #imitations affect the va#i"ity an" ,enera#i/abi#ity of o$r fin"in,s* Nonethe#ess, these !re#iminary res$#ts are enco$ra,in, in that they !oint to the $ti#ity of a !ost hoc a!!roach to refinin, too#s for assessin, s$ici"e ris% (itho$t ris%in, #ives* Jor e3am!#e, f$rther testin, of the SS+ as an in"icator of s$ici"e ris% may #ea" to the i"entification at the time of hos!ita# a"mission of !atients (ho are #i%e#y to e3hibit si,nificant im!rovement in the short r$n* 4hese !atients may benefit from ra!i" reassessment an" referra# to treatment in the comm$nity*

1))!()!+S r. Russ is "irector of ac$te care !sychiatry an" r. Ba#mako$ic%"acila is staff !sychiatrist at 2i##si"e 2os!ita#-North Shore 6on, +s#an" 7e(ish 2ea#th System, 5#en Oa%s, Ne( Kor% 11004 &e-mai#, r$ssL#i.*e"$', (here Mr. "ashdan (as a research assistant (hen this (or% (as "one* Mr. "ashdan is no( a ,ra"$ate st$"ent in the "e!artment of !sycho#o,y at the State Gniversity of Ne( Kor% at ;$ffa#o* r. Pollack is !rofessor of statistics in the com!$ter information systems an" "ecision sciences "e!artment at St* 7ohnFs Gniversity in 7amaica, Ne( Kor%*
R+1+R+(&+S 1* 8ann 77: Psychobio#o,ic !re"ictors of s$ici"e* 7o$rna# of -#inica# Psychiatry 4>&s$!!# 1)':3943, 19>= 6inehan 88: -o,nitive-;ehaviora# 4reatment of ;or"er#ine Persona#ity :isor"er* Ne( Kor%, 5$i#for", 1993

)*

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5*

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>* 5o#ier 7A, 8ar/$% P8, 6eon A-, et a#: 6o( ser$m cho#estero# #eve# an" attem!te" s$ici"e*
American 7o$rna# of Psychiatry 15):419-4)3, 1995DAbstractE 9* Mem!erman +, 0$ss 87, Shearin <: Se#f-in.$rio$s behavior an" moo" re,$#ation in bor"er#ine !atients* 7o$rna# of Persona#ity :isor"ers 11:14 -15=, 199=D8e"#ineE