BURLINGTON, VT — Hospitalization for patients seeking emergency care immediately after a suicide attempt appeared beneficial, but that was not the case with those who had suicide ideation or whose attempt occurred more than a day before, according to a new study.
The decision analytic model found that hospitalization was associated with reduced suicide attempt risk among patients who attempted suicide in the past day but not among others with suicidality. In fact, according to the report in JAMA Psychiatry, “Accounting for heterogeneity, suicide attempt risk was found to increase with hospitalization in 24% of patients and decrease in 28%.”1
The study team, led by researchers from Larner College of Medicine at the University of Vermont and including participation from the VA Center to Improve Veteran Involvement in Care, Portland, OR, the Center of Excellence for Suicide Prevention at the Canandaigua, NY, VAMC and the National Center for PTSD, VA Boston Healthcare System, raised the following question: “Can development of an individualized treatment rule identify patients presenting to emergency departments/urgent care with suicidal ideation or suicide attempts who are likely to benefit from psychiatric hospitalization?”
For patients presenting to an emergency department (ED) or urgent care (UC) with high suicide risk, psychiatric hospitalization is the standard of care. The effect of hospitalization “in reducing subsequent suicidal behaviors is poorly understood and likely heterogeneous,” however, the researchers wrote.
Their study sought to estimate the association of psychiatric hospitalization with subsequent suicidal behaviors. To do that, the team used observational data and developed a preliminary predictive analytics individualized treatment rule, accounting for heterogeneity across patients.
All U.S. veterans presenting with suicidal ideation (SI) or suicide attempt (SA) from Jan. 1, 2010, to Dec. 31, 2015, were included in a machine-learning analysis, which occurred from Sept. 1, 2022, to March 10, 2023. The researchers defined subgroups by primary psychiatric diagnosis—nonaffective psychosis, bipolar disorder, major depressive disorder and other—and suicidality—SI only, SA in past 2–7 days and SA in past day.
The study identified fatal and nonfatal SAs within 12 months of ED/UC visits from administrative records and the National Death Index, while baseline covariates were drawn from electronic health records and geospatial databases.
The authors reported that, of 196,610 visits 71.5% resulted in hospitalization. The cohort was 90.3% men with a median age of 53.
“The 12-month SA risk was 11.9% with hospitalization and 12.0% with nonhospitalization (difference, -0.1%; 95% CI, -0.4% to 0.2%). In patients with SI only or SA in the past 2 to 7 days, most hospitalization was not associated with subsequent SAs,” the researchers wrote.
For patients with SA in the past day, however, hospitalization was associated with risk reductions ranging from -6.9% to -9.6% across diagnoses. “Accounting for heterogeneity, hospitalization was associated with reduced risk of subsequent SAs in 28.1% of the patients and increased risk in 24.0%,” the study noted. “An individualized treatment rule based on these associations may reduce SAs by 16.0% and hospitalizations by 13.0% compared with current rates.”
The authors concluded that the findings of their study suggested that psychiatric hospitalization is associated with reduced average SA risk in the immediate aftermath of an SA but not after other recent SAs or SI only. “Substantial heterogeneity exists in these associations across patients. An individualized treatment rule accounting for this heterogeneity could both reduce SAs and avert hospitalizations,” they wrote.
- Ross EL, Bossarte RM, Dobscha SK, Gildea SM, et al. Estimated Average Treatment Effect of Psychiatric Hospitalization in Patients With Suicidal Behaviors: A Precision Treatment Analysis. JAMA Psychiatry. 2023 Oct 18. doi: 10.1001/jamapsychiatry.2023.3994. Epub ahead of print. PMID: 37851457.