Suicide risk after a suicide attempt Is highest in people with bipolar disorder and schizophrenia

Two linked studies explore the risk of non-fatal self harm after discharge from a psychiatric hospital and the factors associated with the risk of suicide after a suicide attempt.1 2 Suicide is one of the 10 leading causes of death worldwide and will represent about 2.4% of the global burden of disease by 2020, with about 1.5 million people dying from suicide each year.3 Making the prevention of suicide a health service and public health priority is justified on medical, ethical, and cost effectiveness grounds.4 5 Previous attempts at suicide increase the risk of suicide 30-40 times.6 A history of deliberate self harm is the strongest predictor of future suicidal behaviour.7 A systematic review found that 16% of patients who attended an accident and emergency department as a result of deliberate self harm repeated this behaviour and 1.8% died by suicide.8 On the basis of a large Swedish cohort study of almost 40 000 people admitted to hospital because of attempted suicide, Tidemalm and colleagues report how many suicides were completed over 30 years.1 They found that the type of co-occurring psychiatric disorder was an important factor for the overall risk of a completed suicide after an attempted one. The strongest predictors of completed suicide throughout the follow-up period were schizophrenia (men: adjusted hazard ratio 4.1, 95% confidence interval 3.5 to 4.8; women: 3.5, 2.8 to 4.4) and bipolar disorder (men: 3.5, 3.0 to 4.2; women: 2.5, 2.1 to 3.0). The authors also explored the population attributable fractions for suicide. In line with previous evidence, they found that women with depression or bipolar disorder and men with schizophrenia have a significantly increased risk of death by suicide. The risk assessment of suicidal behaviour should not only include psychiatric comorbidity because other factors such as previous self harm are important. The second linked study, by Gunnell and colleagues, assesses the risk of non-fatal self harm in about 75 000 patients for up to one year after their discharge from psychiatric inpatient care.2 Of the total sample, 6% were admitted to hospital because of self harm within 12 months of discharge. Further evidence of the need for intensive aftercare is that a third of these episodes occurred in the first four weeks after discharge. As expected, admission for self harm to a psychiatric unit during the year before admission was one of the strongest risk factors for self harm after discharge. The risk was higher for women than for men. It was also higher in younger patients and in those with a shorter length of inpatient stay. Gunnell and colleagues emphasise that patients with personality disorders, depression, and substance misuse have a high risk for self harm. What are the practical implications for clinicians? The care of patients who attempt suicide or deliberately harm themselves should include routine psychiatric and psychosocial assessment and standardisation. Up to 45% of patients who deliberately harm themselves leave accident and emergency departments without being comprehensively assessed by a suitably qualified healthcare professional or do not receive a specialist psychosocial assessment.9 10 Routine psychiatric assessment might be the most important initial step when organising aftercare. As Gunnell and colleagues report,2 depression and substance misuse are important risk factors for self harm after discharge. These problems are often undiagnosed in patients with deliberate self harm as a consequence of non-standardised procedures for assessment and aftercare.11 12 Systematic referral to professional services before and after discharge is therefore recommended. Depression, bipolar disorder, and schizophrenia are the strongest predictors of suicide risk in people who have attempted suicide. For these people, aftercare should also include education of their immediate family and friends. In addition, recent studies found that contacting patients by telephone one month after discharge from an emergency department for deliberate self poisoning may reduce the number of repeat episodes.13 Self poisoning is one of the most common methods of attempted suicide, so access to toxic substances needs to be restricted; this will require better regulation by public authorities.