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- Title
Premature Death, Suicide, and Nonlethal Intentional Self-Harm After Psychiatric Discharge.
- Authors
Mortier, Philippe; Conde, Susana; Alayo, Itxaso; Amigo, Franco; Ballester, Laura; Cirici Amell, Roser; Guinart, Daniel; Contaldo, Salvatore Fabrizio; Ferrer, Montserrat; Leis, Angela; Mayer, Miguel Angel; Portillo-Van Diest, Ana; Puértolas-Gracia, Beatriz; Ramírez-Anguita, Juan Manuel; Peña-Salazar, Carlos; Sanz, Ferran; Kessler, Ronald C.; Palao, Diego; Pérez Sola, Víctor; Mehlum, Lars
- Abstract
This cohort study estimates rates of all-cause premature death, suicide, and nonlethal intentional self-harm after discharge from a psychiatric hospitalization among patients in Spain and investigates associations of these outcomes with variables including sex and mental disorders. Key Points: Question: What is the risk for premature death, suicide, and nonlethal intentional self-harm following discharge from psychiatric hospitalization? Findings: In this cohort study including 49 108 patients, risk for postdischarge premature death (age <70 years) and suicide was significantly higher compared with the general population. Premature death was associated with cognitive disorders and alcohol-related disorders in both sexes; suicide was associated with postdischarge nonlethal intentional self-harm in both sexes, with depressive and adjustment disorders in males, and with bipolar disorder in females. Meaning: The findings suggest individuals discharged from psychiatric inpatient care constitute a vulnerable population for premature death and suicidal behavior. Importance: There is a need for representative research on serious adverse outcomes following discharge from psychiatric hospitalization. Objective: To compare rates of premature death, suicide, and nonlethal intentional self-harm after psychiatric discharge with rates in the general population and investigate associations of these outcomes with relevant variables associated with the index psychiatric hospitalization. Design, Setting, and Participants: This retrospective cohort study included all residents from Catalonia, Spain (7.6 million population), who had psychiatric hospitalizations between January 1, 2014, and December 31, 2018, and were older than 10 years at the index (first) hospitalization. Follow-up was until December 31, 2019. Statistical analysis was performed from December 1, 2022, through April 11, 2024. Exposures: Socioeconomic status, psychiatric diagnoses, duration of index hospitalization, and number of previous psychiatric hospitalizations. Main Outcomes and Measures: Postdischarge premature death (ie, all-cause death before age 70 years) and suicide (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] code range X60-X84), identified using mortality data, and postdischarge nonlethal intentional self-harm, identified using electronic health record and self-harm case register data. Standardized mortality ratios (SMRs) compared rates of premature death and suicide between the cohort and the general population. Fully adjusted, multivariable, cause-specific Cox proportional hazards regression models for the 3 outcomes were fitted. Results: A total of 49 108 patients discharged from psychiatric hospitalization were included (25 833 males [52.6%]; mean [SD] age at discharge, 44.2 [18.2] years). During follow-up, 2260 patients (4.6%) died prematurely, 437 (0.9%) died by suicide, and 4752 (9.7%) had an episode of nonlethal intentional self-harm. The overall SMR for premature death was 7.5 (95% CI, 7.2-7.9). For suicide, SMR was 32.9 (95% CI, 29.9-36.0) overall and was especially high among females (47.6 [95% CI, 40.2-54.9]). In fully adjusted sex-stratified hazard models, postdischarge premature death was associated with cognitive disorders (adjusted hazard ratio [AHR], 2.89 [95% CI, 2.24-3.74] for females; 2.59 [95% CI, 2.17-3.08] for males) and alcohol-related disorders (AHR, 1.41 [95% CI, 1.18-1.70] for females; 1.22 [95% CI, 1.09-1.37] for males). Postdischarge suicide was associated with postdischarge intentional self-harm (AHR, 2.83 [95% CI, 1.97-4.05] for females; 3.29 [95% CI, 2.47-4.40] for males), with depressive disorders (AHR, 2.13 [95% CI, 1.52-2.97]) and adjustment disorders (AHR, 1.94 [95% CI, 1.32-2.83]) among males, and with bipolar disorder among females (AHR, 1.94 [95% CI, 1.21-3.09]). Postdischarge intentional self-harm was associated with index admissions for intentional self-harm (AHR, 1.95 [95% CI, 1.73-2.21] for females; 2.62 [95% CI, 2.20-3.13] for males) as well as for adjustment disorders (AHR, 1.48 [95% CI, 1.33-1.65] for females; 1.99 [95% CI, 1.74-2.27] for males), anxiety disorders (AHR, 1.24 [95% CI, 1.10-1.39] for females; 1.36 [95% CI, 1.18-1.58] for males), depressive disorders (AHR, 1.54 [95% CI, 1.40-1.69] for females; 1.80 [95% CI, 1.58-2.04] for males), and personality disorders (AHR, 1.59 [95% CI, 1.46-1.73] for females; 1.43 [95% CI, 1.28-1.60] for males). Conclusions and Relevance: In this cohort study of patients discharged from psychiatric hospitalization, risk for premature death and suicide was significantly higher compared with the general population, suggesting individuals discharged from psychiatric inpatient care are a vulnerable population for premature death and suicidal behavior.
- Subjects
SPAIN; SUICIDE risk factors; MORTALITY risk factors; SELF-injurious behavior; PSYCHIATRIC treatment; RESEARCH funding; SOCIOECONOMIC factors; MENTAL illness; SEX distribution; CAUSES of death; DISCHARGE planning; RETROSPECTIVE studies; SPANIARDS; DESCRIPTIVE statistics; PERSONALITY disorders; LONGITUDINAL method; ALCOHOL-induced disorders; SUICIDE; ELECTRONIC health records; COGNITION disorders; DATA analysis software; LENGTH of stay in hospitals; CONFIDENCE intervals; COMPARATIVE studies; PROPORTIONAL hazards models
- Publication
JAMA Network Open, 2024, Vol 7, Issue 6, pe2417131
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2024.17131