0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

1
Articles   |    
Suicide Risk Among U.S. Service Members After Psychiatric Hospitalization, 2001–2011
David D. Luxton, Ph.D.; Lily Trofimovich, M.S.; Leslie L. Clark, Ph.D.
Psychiatric Services 2013; doi: 10.1176/appi.ps.201200413
View Author and Article Information

Dr. Luxton is affiliated with the National Center for Telehealth and Technology, 9933 West Hayes St., Joint Base Lewis-McChord, Tacoma, WA 98431 (e-mail: david.d.luxton@mail.mil). Ms. Trofimovich and Dr. Clark are with the Armed Forces Health Surveillance Center, Silver Spring, Maryland.

Copyright © 2013 by the American Psychiatric Association

Objective  The rising rate of suicide and the increase in psychiatric hospitalizations in the U.S. military underscore the need to determine risk among service members in psychiatric care so that targeted interventions and prevention programs are implemented. The purpose of this study was to determine the suicide rates of active-duty U.S. service members after discharge from a psychiatric hospitalization.

Methods  Data from 68,947 patients who had psychiatric hospitalizations at military treatment facilities between 2001 and 2011 were obtained from the Defense Medical Surveillance System. Rates of suicide were compared between the cohort group and the general active-duty U.S. military population. Survival analysis was used to determine time-dependent patterns of suicide after hospital discharge.

Results  A total of 153 suicides occurred among the 68,947 service members. The overall suicide rate in the cohort was 71.6 per 100,000 person-years, compared with the rate of 14.2 per 100,000 person-years in the general active-duty U.S. military population. Personnel released from a psychiatric hospitalization were therefore five times more likely to die from suicide. The risk of dying from suicide within the first 30 days after a psychiatric hospitalization was 8.2 times higher than the risk at more than one year after hospitalization.

Conclusions  Active-duty U.S. service members who are released from a psychiatric hospitalization are a group at high risk of suicide. Aggressive safety planning and targeted interventions during and after hospitalization are recommended.

Abstract Teaser
Figures in this Article

The high rates of suicide and repeat suicide attempts among patients discharged from psychiatric hospitalization are documented in the literature (13). Studies have shown that most posthospitalization suicides occur during the first few weeks after discharge and that many suicides occur before the first follow-up appointment (4,5). Some of the primary factors that may contribute to posthospitalization suicide risk include reduced clinical supervision, noncompliance with aftercare treatment, and brief hospitalizations that do not allow sufficient time for effective treatment of suicidality (3). A return to stressful conditions, disconnection from care resources, and social isolation may also increase risk (3,6).

A study by Valenstein and colleagues (7) examined suicide rates among 887,859 U.S. military veterans who were in treatment for depression at Department of Veterans Affairs (VA) hospitals between 1999 and 2004. The suicide rate within the first 12 weeks after a psychiatric hospital stay was 568 per 100,000 person-years, which was approximately five times the base rate for the overall treatment population and 54 times the rate for the general U.S. population during the same period. The risk for suicide among active-duty U.S. service members discharged from a psychiatric hospitalization, however, has yet to be examined. The rising rate of suicide (8) and the increase in psychiatric hospitalizations (9) in the U.S. military underscore the need to determine risk among service members in psychiatric care so that targeted interventions and prevention programs are implemented.

The purpose of this study was to conduct a retrospective analysis to determine suicide rates among active-duty U.S. service members who had psychiatric hospitalizations at military treatment facilities. Survival analysis was used to examine time-dependent patterns of suicide after hospital discharge.

The cohort consisted of 68,947 active-duty U.S. service members who had psychiatric hospitalizations at military treatment facilities between January 1, 2001, and December 31, 2011 (the surveillance period). Data on demographic characteristics, personnel data, and medical data were obtained from the Defense Medical Surveillance System, and Medical Expense and Performance Reporting System codes were used to identify psychiatric inpatient facilities within military treatment facilities. Person-level demographic data and primary psychiatric diagnoses (at most recent hospitalization during the surveillance period) were examined for both the entire cohort and the subcohort of persons who died by suicide. For the comparison with the overall population rate, person-years were calculated from the service member’s entry into active service until death, separation from service, or end of the surveillance period.

A survival analysis was conducted with the generalized linear model procedure in SAS, version 9.2. Person-years for this analysis began at hospital discharge. As in other published studies, risk periods (days after release from hospitalization) were delineated as 1–30 days, 31–60 days, 61–90 days, 121–150 days, 151–180 days, 181–365 days, and over one year. Gender, age at hospital admission, service (Air Force, Army, Navy, and Marine Corps), and number of prior psychiatric hospitalizations were treated as covariates. Incidence rates, crude risk ratios, and adjusted risk ratios for each of the risk periods were computed with “over one year after discharge” as the reference group.

This analysis was conducted by duly constituted public health authorities who have been directed to conduct public health surveillance on the incidence and prevalence of suicide and risk factors contributing to suicide in military members. Per regulation (45 CFR 46.101/102), this activity does not constitute research, and institutional review board examination was not required.

+

Descriptive statistics

Of the 304 deaths in the cohort group, 153 (50%) were from suicide, 93 (31%) were from accidents, 30 (10%) were from natural causes, and 28 (9%) were from combat or homicide or were pending and undetermined. As shown in Table 1, most service members who died by suicide were white, non-Hispanic, married men in the 20- to 29-year age group. The most frequent primary psychiatric diagnoses among those who died by suicide were adjustment reaction, episodic mood disorder, and depressive disorder not elsewhere classified. Two percent of those who died by suicide had a primary diagnosis of posttraumatic stress disorder.

 
Anchor for Jump
Table 1Characteristics of active-duty military personnel who had a psychiatric hospitalization at a military facility, 2001–2011
+

Suicide rate and survival analysis

The overall suicide rate in this cohort of active-duty U.S. military personnel who had been discharged from a psychiatric hospitalization was 71.6 per 100,000 person-years. The rate of suicide in the general active-duty U.S. military population during 2001–2011 (baseline rate) was 14.2 per 100,000 person-years. Thus suicides among U.S. service members who had had a psychiatric hospitalization were five times more likely than among the general active-duty U.S. military population.

The results of the survival analysis are shown in Table 2. Suicide rates were highest within the first 90 days after hospital discharge, with the highest rate in the first 30 days. When adjusted for number of hospitalizations, gender, age, and service, the risk of suicide was approximately 8.2 times higher in the first 30 days, five times higher in the 31- to 60-day and 61- to 90-day posthospitalization periods, and twice as high for all remaining risk periods, compared with the risk at more than one year posthospitalization.

 
Anchor for Jump
Table 2Suicides rates (N=153) of active-duty military personnel who had a psychiatric hospitalization at a military facility, 2001–2011, by period after hospital discharge
Table Footer Note

a Reference group: suicides occurring >1 year after discharge

Table Footer Note

bAdjusted for service, number of hospitalizations, age, and gender

The results of this study indicate that the risk of suicide was considerably higher among U.S. military personnel who were recently released from psychiatric hospitalizations than in the general active-duty U.S. military population. The suicide rates were highest within 90 days after discharge and especially high within the first 30 days after discharge. These findings are consistent with other published studies that indicate that risk is highest in the 30 days after hospital discharge.

The results of this study highlight the importance of safety planning, continuity of care, and evidence-based prevention interventions both during and after psychiatric inpatient treatment. Several suicide prevention interventions that specifically address suicide risk among psychiatric inpatients are currently being evaluated. Collaborative assessment and management of suicidality (10), for example, is a structured, collaborative approach to suicide risk assessment, risk reduction, treatment planning, and therapeutic alliance–building that has been adapted and tested for inpatient psychiatric settings (11). Postadmission cognitive therapy is another intervention that is currently being tested for inpatients who have been hospitalized for a recent suicide attempt (12). This collaborative brief intervention is administered at individual therapy sessions during hospitalization and also involves collaboration with the unit’s social work team to identify outpatient resources for patients. An intervention that specifically addresses posthospitalization suicide risk is the caring letters concept (6,13). The caring letters concept entails sending brief and compassionate correspondence to recently discharged patients and is the only intervention shown in a randomized controlled trial to reduce suicide mortality rates (14). A caring letters program has been pilot-tested at a large military treatment facility (15), and a large randomized control trial to investigate this specific program is under way at multiple military and VA hospitals (6).

Some limitations to this study should be noted. First, the analysis was limited to active-duty military personnel who were treated within the Military Health System (MHS) and did not include service members who were hospitalized outside the MHS network or who were discharged from military service during the surveillance period. Thus the data may underestimate the true rate of suicide in the cohort. Second, the small number of suicide cases limited a more thorough examination of risk based on risk periods, demographic characteristics, and diagnostic categories. Also, rates based on small counts may be unstable and should be interpreted with caution. Future research that includes inpatient treatment encounters from all inpatient facilities (within and outside the MHS network) would provide a larger population to address these issues.

Active-duty U.S. service members who were recently discharged from a psychiatric hospitalization were found to be at high risk of suicide. This study highlights the importance of targeted suicide interventions during and after inpatient stays, as well as close follow-up and monitoring, especially within 30 days of hospital release. Structured transition programs and aggressive follow-up after hospital discharge are recommended.

Opinions and assertions expressed in this article should not be construed as reflecting official views, policies, or positions of the Department of Defense or the United States Government.

The authors report no competing interests.

Goldacre  M;  Seagroatt  V;  Hawton  K:  Suicide after discharge from psychiatric inpatient care.  Lancet 342:283–286, 1993
[CrossRef] | [PubMed]
 
Meehan  J;  Kapur  N;  Hunt  IM  et al:  Suicide in mental health in-patients and within 3 months of discharge: national clinical survey.  British Journal of Psychiatry 188:129–134, 2006
[CrossRef] | [PubMed]
 
Knesper  DJ:  Continuity of Care for Suicide Prevention and Research: Suicide Attempts and Suicide Deaths Subsequent to Discharge From the Emergency Department or Psychiatry Inpatient Unit .  Newton, Mass,  Education Development Center, Inc, 2012
 
Qin  P;  Nordentoft  M:  Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers.  Archives of General Psychiatry 62:427–432, 2005
[CrossRef] | [PubMed]
 
Hunt  IM;  Kapur  N;  Webb  R  et al:  Suicide in recently discharged psychiatric patients: a case-control study.  Psychological Medicine 39:443–449, 2009
[CrossRef] | [PubMed]
 
Luxton  DD;  June  JD;  Comtois  KA:  Can post-discharge follow-up contacts prevent suicide and suicide behavior? A review of the evidence.  Crisis 34:32–41, 2013
[PubMed]
 
Valenstein  M;  Kim  HM;  Ganoczy  D  et al:  Higher-risk periods for suicide among VA patients receiving depression treatment: prioritizing suicide prevention efforts.  Journal of Affective Disorders 112:50–58, 2009
[CrossRef] | [PubMed]
 
Luxton DD, Osenbach JE, Reger MA, et al: Department of Defense Suicide Event Report: Calendar Year 2011 Annual Report. Tacoma, Wash, National Center for Telehealth and Technology, Defense Centers of Excellence for Psychological Health and TBI, 2012
 
 Hospitalizations among members of the active component, US Armed Forces, 2011.  Medical Surveillance Monthly Report 19(4):10–16, 2012
 
Jobes  DA:  Managing Suicidal Risk: A Collaborative Approach .  New York,  Guilford, 2006
 
Ellis  TE;  Daza  P;  Allen  JG:  Collaborative assessment and management of suicidality at Menninger (CAMS-M): an inpatient adaptation and implementation.  Bulletin of the Menninger Clinic 76:147–171, 2012
[CrossRef] | [PubMed]
 
Ghahramanlou-Holloway  M;  Cox  D;  Greene  F:  Post-admission cognitive therapy: a brief intervention for psychiatric inpatients admitted after a suicide attempt.  Cognitive and Behavioral Practice 19:233–244, 2012
[CrossRef]
 
Motto  JA:  Suicide prevention for high-risk persons who refuse treatment.  Suicide and Life-Threatening Behavior 6:223–230, 1976
[PubMed]
 
Motto  JA;  Bostrom  AG:  A randomized controlled trial of postcrisis suicide prevention.  Psychiatric Services 52:828–833, 2001
[CrossRef] | [PubMed]
 
Luxton  DD;  Kinn  JT;  June  JD  et al:  The caring letters project: a military suicide prevention pilot program.  Crisis 33:5–12, 2012
[PubMed]
 
References Container
Anchor for Jump
Table 1Characteristics of active-duty military personnel who had a psychiatric hospitalization at a military facility, 2001–2011
Anchor for Jump
Table 2Suicides rates (N=153) of active-duty military personnel who had a psychiatric hospitalization at a military facility, 2001–2011, by period after hospital discharge
Table Footer Note

a Reference group: suicides occurring >1 year after discharge

Table Footer Note

bAdjusted for service, number of hospitalizations, age, and gender

+

References

Goldacre  M;  Seagroatt  V;  Hawton  K:  Suicide after discharge from psychiatric inpatient care.  Lancet 342:283–286, 1993
[CrossRef] | [PubMed]
 
Meehan  J;  Kapur  N;  Hunt  IM  et al:  Suicide in mental health in-patients and within 3 months of discharge: national clinical survey.  British Journal of Psychiatry 188:129–134, 2006
[CrossRef] | [PubMed]
 
Knesper  DJ:  Continuity of Care for Suicide Prevention and Research: Suicide Attempts and Suicide Deaths Subsequent to Discharge From the Emergency Department or Psychiatry Inpatient Unit .  Newton, Mass,  Education Development Center, Inc, 2012
 
Qin  P;  Nordentoft  M:  Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers.  Archives of General Psychiatry 62:427–432, 2005
[CrossRef] | [PubMed]
 
Hunt  IM;  Kapur  N;  Webb  R  et al:  Suicide in recently discharged psychiatric patients: a case-control study.  Psychological Medicine 39:443–449, 2009
[CrossRef] | [PubMed]
 
Luxton  DD;  June  JD;  Comtois  KA:  Can post-discharge follow-up contacts prevent suicide and suicide behavior? A review of the evidence.  Crisis 34:32–41, 2013
[PubMed]
 
Valenstein  M;  Kim  HM;  Ganoczy  D  et al:  Higher-risk periods for suicide among VA patients receiving depression treatment: prioritizing suicide prevention efforts.  Journal of Affective Disorders 112:50–58, 2009
[CrossRef] | [PubMed]
 
Luxton DD, Osenbach JE, Reger MA, et al: Department of Defense Suicide Event Report: Calendar Year 2011 Annual Report. Tacoma, Wash, National Center for Telehealth and Technology, Defense Centers of Excellence for Psychological Health and TBI, 2012
 
 Hospitalizations among members of the active component, US Armed Forces, 2011.  Medical Surveillance Monthly Report 19(4):10–16, 2012
 
Jobes  DA:  Managing Suicidal Risk: A Collaborative Approach .  New York,  Guilford, 2006
 
Ellis  TE;  Daza  P;  Allen  JG:  Collaborative assessment and management of suicidality at Menninger (CAMS-M): an inpatient adaptation and implementation.  Bulletin of the Menninger Clinic 76:147–171, 2012
[CrossRef] | [PubMed]
 
Ghahramanlou-Holloway  M;  Cox  D;  Greene  F:  Post-admission cognitive therapy: a brief intervention for psychiatric inpatients admitted after a suicide attempt.  Cognitive and Behavioral Practice 19:233–244, 2012
[CrossRef]
 
Motto  JA:  Suicide prevention for high-risk persons who refuse treatment.  Suicide and Life-Threatening Behavior 6:223–230, 1976
[PubMed]
 
Motto  JA;  Bostrom  AG:  A randomized controlled trial of postcrisis suicide prevention.  Psychiatric Services 52:828–833, 2001
[CrossRef] | [PubMed]
 
Luxton  DD;  Kinn  JT;  June  JD  et al:  The caring letters project: a military suicide prevention pilot program.  Crisis 33:5–12, 2012
[PubMed]
 
References Container
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Web of Science® Times Cited: 3

Related Content
Articles
Books
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 39.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 39.  >
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 62.  >
DSM-5™ Clinical Cases > Chapter 7.  >
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 62.  >
Topic Collections
Psychiatric News
APA Guidelines
PubMed Articles