Preventing patients from leaving psychiatric wards without staff agreement could avoid up to 50 suicide deaths every year, say University of Manchester researchers.
A new report by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness suggests that the ward environment may play a part in the level of patients leaving the ward, and that attempts should be made to optimise it. It also urges mental health services to improve awareness among staff of the antecedents of suicide among high-risk groups.
The study, published in the journal BMC Psychiatry, collected data on 50,352 people who had died by suicide or unexplained causes in England and Wales between 1997 and 2006.
During this 10-year period there were 13,331 suicide deaths in individuals who had been in contact with mental health services in the year prior to death, of which 1,851, or 14%, were suicides by current psychiatric patients. The report noted that patient deaths had fallen sharply over the course of the study period, from 221 in 1997 to 141 in 2006.
The majority of the 1,851 patient cases - 1,292, or 70% - occurred off the ward: 469 of these suicides were by patients who had absconded from the ward. The remaining 761 had been given permission to leave the ward.
"Our findings have confirmed previous studies that a substantial proportion of in-patient suicide deaths occur after absconding from the ward," said Dr Isabelle Hunt, who led the research in the University's Centre for Suicide Prevention.
"Over the 10-year study period, while the number of in-patient suicide deaths declined, the proportion of these deaths which occurred among patients who had absconded remained unchanged at about 40%."
The team were also able to identify different character traits of vulnerable patients, as well as the most likely method of suicide by different patient groups.
"Compared to individuals who died when they were off the ward with staff agreement, those who absconded were more likely to be young, unemployed and homeless," said Dr Hunt. "Schizophrenia was the most common diagnosis, and rates of previous violence and substance misuse were high.
"Those who died following absconding were more likely than in-patients on agreed leave to have been formally detained for treatment, be non-compliant with medication, and to have died in the first week of admission. The method of suicide was also more likely to be violent compared to other in-patients, with nearly half of absconders dying by jumping."
The researchers suggest that improving the ward environment to provide a more supportive and less intimidating experience may contribute to reduced risk. They also state that tighter control of ward exits and more intensive observation of patients, particularly in the early days of admission, might be one way to limit the likelihood of a patient taking their own life.
Dr Hunt added: "It is clearly a challenge to prevent patients leaving a general psychiatry open ward but our findings can inform staff of the clinical characteristics associated with absconding suicides, such as schizophrenia, substance misuse and noncompliance.
"Particular attention could be paid by staff in observing not only the patients themselves but also ward exits, while improved ward security through video monitoring or swipe-card systems to regulate patients' entry and exit may be effective.
"Other measures to prevent in-patient suicide might include regular risk assessments during recovery and prior to granting leave, staff-training programmes in the management of risk, and improved staff communication."
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Suicide amongst psychiatric in-patients who abscond from the ward: a national clinical survey, Isabelle M Hunt, Kirsten Windfuhr, Nicola Swinson, Jenny Shaw, Louis Appleby, Nav Kapur and the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, BMC Psychiatry (in press), www.biomedcentral.com/bmcpsychiatry/