SUICIDE PRECAUTIONS FOR PSYCHIATRIC INPATIENTS: A REVIEW Peter Cheung
This paper reviews the literature on the assessment and management of suicide risk of psychiatric inpatients. Even though a large number of scales have been developed to assist the prediction of suicide for patients admitted for suicide ideas and attempts, none of them were designed to predict suicide in the short term. However the Modified Suicide Intent Scale and the Hopelessness Scale appear to have the potential to predict immediate suicide risk. Risk factors associated with specific psychiatric conditions were all derived retrospectively and their predictive validities have not been established by prospective studies. Important issues relating to the management of suicidal inpatients, such as staff-patient relationships, use of constant observation and medical-legal aspects are reviewed. Australian and New Zealand Journal of Psychiatry 1992; 26:592-598 Most suicides do not occur within hospitals. Only 0.5% of all suicides in the US. occur in general hospital [ 11. In the U.K. 5 % of all suicides occur among hospital inpatients [2]. However the suicide rate in hospital is often much higher than that of the general population [3,4,5,6]. There has been a recent increase in the rate of inpatient suicides [2,4]. Inpatient suicides are well known to generate tremendous staff anxiety, guilt and other distressing reactions [7,8]. It also often leads, at least in the US, to litigation involving the hospital and staff concerned. Parker [9] and Cantor [ 101 have recently discussed future trends in litigation for suicides during psychiatric care in Australia. Unfortunately psychiatrists are not good at assessing the imminent suicide risk [ 11,121. The assessment of suicide risk is often done at a clinical-in-
University of Otago, and Otago Area Health Board, Dunedin Hospital, Great King Street, Dunedin, New Zealand Peter Cheung MBBS, DPM, MRCPsych, FRANZCP, Clinical Lecturer and Consultant Psychiatrist
tuitive level and there is no generally accepted measuring instrument to assist the clinician [ 131. Even after the suicide risk has been identified, standards for reasonable psychiatric care with regard to suicide prevention are often unclearly stated and inconsistently applied [ 11.
Assessment of inpatient suicide risk Suicide predictors are only relevant for specific patient populations [ 141. Thus the focus in this paper will be on studies pertaining to suicide among psychiatric inpatients. There is often a lack of differentiation between short term and long term risk factors, even though the significances of the two are obviously different [ 151. Short term risk factors pertain to the period of the next few hours, days or weeks, whereas long term risk factors pertain to the period of the next few months or years. The emphasis here is on short term factors as they are obviously more important than long term factors as far as inpatient management is concerned.
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However long term factors are important in considering leave, discharge and follow up plans for the patient.
Studies on those hospitalised for suicide attempts and suicide ideas Many scales have been developed to assist the prediction of suicide among suicide attempters admitted for inpatient treatment [ 16-21]. These scales usually comprise sociodemographic and clinical variables which are claimed to be capable of differentiating the suicide attempters from those who eventually commit suicide. The predictive validity of some of these scales has been established by prospective studies involving large samples of suicide attempters [18,19]. However they are all designed to determine suicide risk in the long term and their value in determining the short term risk is rather unclear. The only exception appears to be the Modified Suicide Intent (MSI) Scale [ 18,191. This scale determines the suicide intent by the circumstances surrounding the attempt and the subject's reported mental state at the time of the attempt, and assesses the medical risk involved including the subject's own knowledge of the risk. It appears to afford a clinical estimate of a person's propensity to suicide right after the suicide attempt [ 181. Pierce's five year follow up study [ 191, in which MSI scores were recorded for the index suicide and also repeat suicide attempts, showed that none of those who were low scorers (0-3) died by suicide as a result of their next suicidal attempt, and there was a trend towards high scorers among those who later killed themselves. Another group of studies on suicide attempters focus on the relationship between suicide intent and hopelessness [22-26]. Hopelessness as measured by the Hopelessness Scale [27] was found by a validation study to account for 76% of the association between depression and suicide intent in 384 hospitalised suicide attempters (221. When patients who had been hospitalised for suicide ideation rather than a recent suicide attempt were studied, it was also found that hopelessness, rather than depression per. se, was a determinant of suicide intent [28,29]. According to a recent 10 year prospective study of patients hospitalised with suicide ideation [30], a cut-off point of 9 in the Hopelessness Scale, which has a maximum possible score of 20, was clearly able to separate those who eventually died by
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suicide from those who did not. However even though the false negative rate was low at 1.3%, the false positive rate was 88.4%; most patients who scored above 9 did not eventually commit suicide. Thus hopelessness appears to be an important factor to evaluate in assessing suicide risk. Beck and colleagues [31 ] believe that it can alert the clinician to the immediate as well as the long term suicide potential as it is considered to have both state and trait characteristics. Howeverthis will require validation by future research.
Studies of suicide in specific psychiatric disorders Graham and Burvill [32] found that 90% of suicide cases in their study had some identifiable psychiatric symptomatology, with minor affective symptoms being the most common. They commented that this finding is consistent with those of other studies, and that psychiatric condition is not a sufficient cause of suicide but is probably a necessary one. There are several psychiatric conditions that are more likely to have a suicidal outcome than are other conditions I141. However these are all common conditions and only a minority with each condition appears to be at risk of suicide. It is therefore important to identify the specific risk factors in each of these "high risk" conditions. These factors were identified by retrospectively comparing a group of suicide patients (mostly inpatients, but outpatients were also included in some studies) with controls within the same diagnostic category (see studies below). Assessment of suicide risk among patients suffering from Borderline Personality Disorder (BPD) is notoriously difficult. Suicidal or self-mutilating behaviour is one of the diagnostic criteria for BPD, but suicidality among these patients is often an interpersonal manipulative device and they usually do not intend to kill themselves 133,341. However some Borderline patients do commit suicide. Kullgren and colleagues 1351 found that 12% of 134 consecutive psychiatric suicides had BPD as their diagnosis. Kullgren found, by comparing 15 borderline inpatients who committed suicide with 15 controls, that those who committed suicide had [36] extensive previous hospitalisations, a large number of previous suicidal attempts as long term factors, and earlier suicidal attempts during inpatient treatment, presence of psychotic symptoms, countertransference reaction from staff and imminent mandatory discharge as short
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term factors. Thus Borderline patients with these characteristics appear to have a higher lethality as compared with others and their suicidal ideas should not be dismissed lightly as threats. The functional psychoses, in particular schizophrenia, are the most common diagnostic categories [37-401 among psychiatric inpatient suicides. This is probably due to the fact that schizophrenia is the most common diagnostic category in the hospitals surveyed. However it still appears to be over-represented among inpatient suicides even after its rate has been controlled [37,39]. About 10 % of patients suffering from schizophrenia has been estimated to die by suicide [41]. Drake and colleagues [42] reviewed 16 studies on schizophrenic suicides and, by emphasising the studies with adequate comparison groups, found that long term suicide risk factors among schizophrenic patients included: young age, male, many exacerbations and remissions, high premorbid achievement, severe functional deterioration and non-delusional, painful awareness of illness effect. Drake and colleagues [42,43], by reviewing the literature and doing their own study, also found the following factors just prior to suicide: depression (well controlled studies only partially supported this relationship), hopelessness, period of clinical improvement following relapse, signs of agitation and psycho-motor restlessness, and excessive dependence during hospitalisation with demandingness, neediness and fear of discharge, suicidal ideation or threat, and fear of mental disintegration. Among patients suffering from mood disorders or affective disorders, approximately 15% ended their lives by suicide [41]. The long term factors associated with suicide in this condition have been found to include male sex, older age (in females), single status, living alone and previous suicide attempts [44,45,46]. Short term factors include presence of symptoms such as insomnia, impaired memory and self-neglect [44], presence of delusions [47], and being more severely depressed [48] when compared with diagnostically matched controls. The relationship between depression and hopelessness has already been mentioned. The rate of suicide among alcoholic inpatients as compared with other psychiatric inpatients tends to be low [37,39,48]. However, overall about 15% of patients with alcoholism eventually commit suicide [41]. Long term factors associated with suicide among alcoholic patients include [49]: previous suicide attempt, poor physical health and poor work record during the pre-
vious four years. Regarding short term factors, Murphy and colleagues [50] found that one third of alcoholic patients who killed themselves had experienced the loss of a close relationship within 6 weeks of their death. Many alcoholics had experienced interpersonal loss in their past, and factors that made them succumb on the final occasion appeared to include loss of control of the relationship with an element of finality and an element of shame and defeat [51 I. Specific risk factors associated with other psychiatric conditions have not been sufficiently clarified [52-561.
Studies on suicide in physical diseases Chronic serious physical diseases are associated with an increased risk of suicide [57-611. The suicide risk in these conditions usually appears to be associated with significant depression and it is rare the patient takes a “rational” decision to end hisher life [62]. Apart from the association with depression, these studies have not examined the long term or short term risk factors associated with either physical conditions in general or specific physical conditions in particular.
Management of Suicidal Inpatients Studies on inpatient suicides Method of suicide: In the U S . , hanging [40,63] and jumping [63] were found to be the most common methods inside the hospital whilst gunshot was the most common method outside the hospital [63]. Penis and colleagues [4] found in Sweden among patients (including outpatients and inpatients), poisoning followed by hanging and drowning were the most common methods among women, and hanging followed by shooting and poisoning were the most common methods among men. These authors all stressed availability as the determinant of the choice of method. Since there is a close relationship between availability and method of suicide, the removal of potentially lethal items from the patient can avert suicide attempts (641. Other authors [65,66] have stressed the importance of social, cultural as well as individual factors as determinants of method of suicide. However the relevance of these factors to inpatient suicides have not been clarified.
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Site of the suicide: The majority of inpatient suicides were found to take place outside the hospital while the patient was on leave, had absconded or had recently been discharged from the hospital [37,38,67,68]. For suicides that took place on the ward, the bathroom and bedroom were the most common sites [38,64]. Patient-staff relationship: Many patients who committed suicide were found to have a deteriorating relationship with others, especially staff, during the last few weeks of their lives. They were often considered by the staff to be demanding, manipulative, excessively dependent and provocative, leading to their alienation by the staff [69,70]. Staff factors such as low staff morale, high staff anxiety, untrained or inadequate staff and absence of the usual consultant on leave [2,68,70,71] have been found to be associated with an increased risk of inpatient suicides.
Studies on the management of inpatient suicide Staff‘s attitude and communication: Rigid, traditional suicide precaution schemes implemented by staff who hold harsh, controlling attitudes have been found to be repressive and counterproductive and to increase the suicide risk of patients [7,8]. Excessive or prolonged preoccupation with suicide precautions would increase staff anxiety and increase the ultimate risk of suicide [5,7,72]. Suicide rate has been found to be high in inpatient units where there is poor communication and confusion regarding the roles and responsibilities of the staff [5,8,68,73]. Constant observation: Constant observation or one to one observation at all times (24 hours a day) has sometimes been criticised as being obtrusive, counterproductive and even increasing the risk of suicide [7]. However, a recent review of suicide precautions policy among general hospitals in the U.S. revealed that constant observation was used to some extent by 92% of the reporting hospitals [74]. There appears to be no scientific evidence that constant observation can increase the risk of suicide. On the other hand, it seems that only one attempt has been made so far to evaluate the use of constant observation (751. Unfortunately, the authors only stated their opinion that constant observation appeared to be effective and practical without actually presenting the evidence. Serious medico-legal consequences could follow when constant observation was not used under appropriate circumstances. Thus some case histories
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of inpatients who committed suicide in the U.S. showed that for those who had been assessed to be at high risk of suicide, and succeeded in killing themselves due to inadequate supervision (in many instances there was some degree of observation but constant observation was not used), both the hospital and the staff concerned could be successfully sued for damages [72,76,77]. However, prolonged constant observation can often induce clinical regression and be counter-therapeutic, especially for patients with personality disorders [75,78]. Treatment issues: Whether the patient is receiving adequate treatment for hisher psychiatric condition is obviously an important question in relation to the management of suicide risk. In particular the early and appropriate use of ECT (electroconvulsive therapy ) as a life saving procedure for depressive suicidal patients and some suicidal schizophrenic patients has been emphasised [7,79]. However Goldstein et a1 [80] did not find the use of ECT to be a significant protective factor against suicide. The use of cognitive therapy to counteract hopelessness and hence suicidal risk has been discussed [ 15.301. However the exact value of such intervention is still unclear [ 151. Patients were often found to be improving at the time of suicide [42,68,73,78]. Thus an apparent, especially a sudden, improvement needs to be evaluated carefully, and continued supervision will be needed for patients whose suicidal thoughts persist despite apparent clinical improvement. Environmental safeguards: Common environmental safeguards that are recommended include suitably located nursing station from which all ward exits can be observed, windows should be of “non-breakable” glass, window openings should be restricted, unnecessary protrusions should be eliminated, all rooms when not in use should be locked, and curtain rods and cloth hooks should be of breakaway variety [5,7,64].
Medico-legal aspects of suicide management In the U.S., about one third of inpatient suicides resulted in lawsuits of which half were against psychiatric hospitals or units [ 11. Another recent review of psychiatric malpractice cases in the States [81] found that the largest group involved suicide or suicide attempt. In the UK, an HM coroner has recently expressed serious concern at the number of suicides committed by psychiatric patients in a communitybased psychiatric service [82]. With increasing em-
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phasis on community care and the consequent limited access to acute inpatient care facilities, suicidal patients could have difficulty in gaining admission, and could be discharged prematurely with potentially serious medico-legal consequences. Courts accept that not all hospital suicides are preventable [83.84] and that professionals are not infallible. There are two common rules that courts appear to use in determining the liability of the hospital and its staff: ( a ) whether the risk involved is “reasonably foreseeable” 177). If the risk can be reasonably foreseen but is not recognised or no appropriate measures are taken to manage the risk, then the professionals involved can be held negligent. (b) Whether “reasonable care and skill” are exercised in the management of the suicidal patient. Here the “conformity test” is commonly applied [72,84]. It refers to whether the care and skill in question conform to an accepted standard of care in keeping with local practice existing at the time. There should be adequate and timely documentation of the evaluation and management of the suicide risk to reduce legal vulnerability in case of litigation [76,85.86]. Proper documentation may be the single most important defence against the charge of malpractice. The reasons and thoughts supporting various decisions in relation to the suicide management should be carefully recorded [ 85,861.It is often suggested that a clearly written suicide precautions policy be established and consistently adhered to in the management of suicidal patients [5,76,87]. Finally, Morgan [82] emphasises that acute inpatient facilities must retain a critical mass so that there are sufficient reserves of staff to provide urgent intensive care when required for suicidal patients.
Conclusion There are many gaps in our knowledge of short term suicide risk predictors. Even though there are some suicide assessment scales for which predictive validity has been established by prospective studies, the focus has only been on the long term factors. The Hopelessness Scale [27] and the Modified Suicide Intent Scale [ 191 are claimed to be useful in the prediction of short term risk. but such claims have not been validated by scientific studies. Also, the short term factors known to be associated with specific psychiatric conditions have all been derived from retrospective studies, and their predictive validity has still to be established by
prospective, controlled studies. It is also not clear whether short term factors as derived from research findings (actuarial data) could be more accurate than the clinical evaluation of the short term suicide risk [ 181, and how much the use of clinical and actuarial information together would enhance the accuracy of the assessment. Regarding studies on the management of suicide risks, the effectiveness of various seemingly sensible strategies has not been validated by proper scientific evaluation. In particular, even though constant observation has been accepted as sound medico-legal practice, at least in the US, it is a costly procedure, the effectiveness of which has not been adequately evaluated. The medico-legal importance of having an explicit suicide precautions policy has often been stressed, but the fundamental question of whether having an explicit suicide precautions protocol is more effective in suicide prevention than not having one has not been addressed. There appears to be a need for prospective, controlled multicentre studies for such questions to be answered.
Acknowledgement Thanks are due to Professor Paul Mullen for his general comments on an earlier draft of this paper.
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This paper reviews the literature on the assessment and management of suicide risk of psychiatric inpatients. Even though a large number of scales have been developed to assist the prediction of suicide for patients admitted for suicide ideas and attempts, none of them were designed to predict suicide in the short term. However the Modified Suicide Intent Scale and the Hopelessness Scale appear to have the potential to predict immediate suicide risk. Risk factors associated with specific psychiatric conditions were all derived retrospectively and their predictive validities have not been established by prospective studies. Important issues relating to the management of suicidal inpatients, such as staff-patient relationships, use of constant observation and medical-legal aspects are reviewed. Australian and New Zealand Journal of Psychiatry 1992; 26:592-598 Most suicides do not occur within hospitals. Only 0.5% of all suicides in the US. occur in general hospital [ 11. In the U.K. 5 % of all suicides occur among hospital inpatients [2]. However the suicide rate in hospital is often much higher than that of the general population [3,4,5,6]. There has been a recent increase in the rate of inpatient suicides [2,4]. Inpatient suicides are well known to generate tremendous staff anxiety, guilt and other distressing reactions [7,8]. It also often leads, at least in the US, to litigation involving the hospital and staff concerned. Parker [9] and Cantor [ 101 have recently discussed future trends in litigation for suicides during psychiatric care in Australia. Unfortunately psychiatrists are not good at assessing the imminent suicide risk [ 11,121. The assessment of suicide risk is often done at a clinical-in-
University of Otago, and Otago Area Health Board, Dunedin Hospital, Great King Street, Dunedin, New Zealand Peter Cheung MBBS, DPM, MRCPsych, FRANZCP, Clinical Lecturer and Consultant Psychiatrist
tuitive level and there is no generally accepted measuring instrument to assist the clinician [ 131. Even after the suicide risk has been identified, standards for reasonable psychiatric care with regard to suicide prevention are often unclearly stated and inconsistently applied [ 11.
Assessment of inpatient suicide risk Suicide predictors are only relevant for specific patient populations [ 141. Thus the focus in this paper will be on studies pertaining to suicide among psychiatric inpatients. There is often a lack of differentiation between short term and long term risk factors, even though the significances of the two are obviously different [ 151. Short term risk factors pertain to the period of the next few hours, days or weeks, whereas long term risk factors pertain to the period of the next few months or years. The emphasis here is on short term factors as they are obviously more important than long term factors as far as inpatient management is concerned.
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However long term factors are important in considering leave, discharge and follow up plans for the patient.
Studies on those hospitalised for suicide attempts and suicide ideas Many scales have been developed to assist the prediction of suicide among suicide attempters admitted for inpatient treatment [ 16-21]. These scales usually comprise sociodemographic and clinical variables which are claimed to be capable of differentiating the suicide attempters from those who eventually commit suicide. The predictive validity of some of these scales has been established by prospective studies involving large samples of suicide attempters [18,19]. However they are all designed to determine suicide risk in the long term and their value in determining the short term risk is rather unclear. The only exception appears to be the Modified Suicide Intent (MSI) Scale [ 18,191. This scale determines the suicide intent by the circumstances surrounding the attempt and the subject's reported mental state at the time of the attempt, and assesses the medical risk involved including the subject's own knowledge of the risk. It appears to afford a clinical estimate of a person's propensity to suicide right after the suicide attempt [ 181. Pierce's five year follow up study [ 191, in which MSI scores were recorded for the index suicide and also repeat suicide attempts, showed that none of those who were low scorers (0-3) died by suicide as a result of their next suicidal attempt, and there was a trend towards high scorers among those who later killed themselves. Another group of studies on suicide attempters focus on the relationship between suicide intent and hopelessness [22-26]. Hopelessness as measured by the Hopelessness Scale [27] was found by a validation study to account for 76% of the association between depression and suicide intent in 384 hospitalised suicide attempters (221. When patients who had been hospitalised for suicide ideation rather than a recent suicide attempt were studied, it was also found that hopelessness, rather than depression per. se, was a determinant of suicide intent [28,29]. According to a recent 10 year prospective study of patients hospitalised with suicide ideation [30], a cut-off point of 9 in the Hopelessness Scale, which has a maximum possible score of 20, was clearly able to separate those who eventually died by
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suicide from those who did not. However even though the false negative rate was low at 1.3%, the false positive rate was 88.4%; most patients who scored above 9 did not eventually commit suicide. Thus hopelessness appears to be an important factor to evaluate in assessing suicide risk. Beck and colleagues [31 ] believe that it can alert the clinician to the immediate as well as the long term suicide potential as it is considered to have both state and trait characteristics. Howeverthis will require validation by future research.
Studies of suicide in specific psychiatric disorders Graham and Burvill [32] found that 90% of suicide cases in their study had some identifiable psychiatric symptomatology, with minor affective symptoms being the most common. They commented that this finding is consistent with those of other studies, and that psychiatric condition is not a sufficient cause of suicide but is probably a necessary one. There are several psychiatric conditions that are more likely to have a suicidal outcome than are other conditions I141. However these are all common conditions and only a minority with each condition appears to be at risk of suicide. It is therefore important to identify the specific risk factors in each of these "high risk" conditions. These factors were identified by retrospectively comparing a group of suicide patients (mostly inpatients, but outpatients were also included in some studies) with controls within the same diagnostic category (see studies below). Assessment of suicide risk among patients suffering from Borderline Personality Disorder (BPD) is notoriously difficult. Suicidal or self-mutilating behaviour is one of the diagnostic criteria for BPD, but suicidality among these patients is often an interpersonal manipulative device and they usually do not intend to kill themselves 133,341. However some Borderline patients do commit suicide. Kullgren and colleagues 1351 found that 12% of 134 consecutive psychiatric suicides had BPD as their diagnosis. Kullgren found, by comparing 15 borderline inpatients who committed suicide with 15 controls, that those who committed suicide had [36] extensive previous hospitalisations, a large number of previous suicidal attempts as long term factors, and earlier suicidal attempts during inpatient treatment, presence of psychotic symptoms, countertransference reaction from staff and imminent mandatory discharge as short
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term factors. Thus Borderline patients with these characteristics appear to have a higher lethality as compared with others and their suicidal ideas should not be dismissed lightly as threats. The functional psychoses, in particular schizophrenia, are the most common diagnostic categories [37-401 among psychiatric inpatient suicides. This is probably due to the fact that schizophrenia is the most common diagnostic category in the hospitals surveyed. However it still appears to be over-represented among inpatient suicides even after its rate has been controlled [37,39]. About 10 % of patients suffering from schizophrenia has been estimated to die by suicide [41]. Drake and colleagues [42] reviewed 16 studies on schizophrenic suicides and, by emphasising the studies with adequate comparison groups, found that long term suicide risk factors among schizophrenic patients included: young age, male, many exacerbations and remissions, high premorbid achievement, severe functional deterioration and non-delusional, painful awareness of illness effect. Drake and colleagues [42,43], by reviewing the literature and doing their own study, also found the following factors just prior to suicide: depression (well controlled studies only partially supported this relationship), hopelessness, period of clinical improvement following relapse, signs of agitation and psycho-motor restlessness, and excessive dependence during hospitalisation with demandingness, neediness and fear of discharge, suicidal ideation or threat, and fear of mental disintegration. Among patients suffering from mood disorders or affective disorders, approximately 15% ended their lives by suicide [41]. The long term factors associated with suicide in this condition have been found to include male sex, older age (in females), single status, living alone and previous suicide attempts [44,45,46]. Short term factors include presence of symptoms such as insomnia, impaired memory and self-neglect [44], presence of delusions [47], and being more severely depressed [48] when compared with diagnostically matched controls. The relationship between depression and hopelessness has already been mentioned. The rate of suicide among alcoholic inpatients as compared with other psychiatric inpatients tends to be low [37,39,48]. However, overall about 15% of patients with alcoholism eventually commit suicide [41]. Long term factors associated with suicide among alcoholic patients include [49]: previous suicide attempt, poor physical health and poor work record during the pre-
vious four years. Regarding short term factors, Murphy and colleagues [50] found that one third of alcoholic patients who killed themselves had experienced the loss of a close relationship within 6 weeks of their death. Many alcoholics had experienced interpersonal loss in their past, and factors that made them succumb on the final occasion appeared to include loss of control of the relationship with an element of finality and an element of shame and defeat [51 I. Specific risk factors associated with other psychiatric conditions have not been sufficiently clarified [52-561.
Studies on suicide in physical diseases Chronic serious physical diseases are associated with an increased risk of suicide [57-611. The suicide risk in these conditions usually appears to be associated with significant depression and it is rare the patient takes a “rational” decision to end hisher life [62]. Apart from the association with depression, these studies have not examined the long term or short term risk factors associated with either physical conditions in general or specific physical conditions in particular.
Management of Suicidal Inpatients Studies on inpatient suicides Method of suicide: In the U S . , hanging [40,63] and jumping [63] were found to be the most common methods inside the hospital whilst gunshot was the most common method outside the hospital [63]. Penis and colleagues [4] found in Sweden among patients (including outpatients and inpatients), poisoning followed by hanging and drowning were the most common methods among women, and hanging followed by shooting and poisoning were the most common methods among men. These authors all stressed availability as the determinant of the choice of method. Since there is a close relationship between availability and method of suicide, the removal of potentially lethal items from the patient can avert suicide attempts (641. Other authors [65,66] have stressed the importance of social, cultural as well as individual factors as determinants of method of suicide. However the relevance of these factors to inpatient suicides have not been clarified.
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Site of the suicide: The majority of inpatient suicides were found to take place outside the hospital while the patient was on leave, had absconded or had recently been discharged from the hospital [37,38,67,68]. For suicides that took place on the ward, the bathroom and bedroom were the most common sites [38,64]. Patient-staff relationship: Many patients who committed suicide were found to have a deteriorating relationship with others, especially staff, during the last few weeks of their lives. They were often considered by the staff to be demanding, manipulative, excessively dependent and provocative, leading to their alienation by the staff [69,70]. Staff factors such as low staff morale, high staff anxiety, untrained or inadequate staff and absence of the usual consultant on leave [2,68,70,71] have been found to be associated with an increased risk of inpatient suicides.
Studies on the management of inpatient suicide Staff‘s attitude and communication: Rigid, traditional suicide precaution schemes implemented by staff who hold harsh, controlling attitudes have been found to be repressive and counterproductive and to increase the suicide risk of patients [7,8]. Excessive or prolonged preoccupation with suicide precautions would increase staff anxiety and increase the ultimate risk of suicide [5,7,72]. Suicide rate has been found to be high in inpatient units where there is poor communication and confusion regarding the roles and responsibilities of the staff [5,8,68,73]. Constant observation: Constant observation or one to one observation at all times (24 hours a day) has sometimes been criticised as being obtrusive, counterproductive and even increasing the risk of suicide [7]. However, a recent review of suicide precautions policy among general hospitals in the U.S. revealed that constant observation was used to some extent by 92% of the reporting hospitals [74]. There appears to be no scientific evidence that constant observation can increase the risk of suicide. On the other hand, it seems that only one attempt has been made so far to evaluate the use of constant observation (751. Unfortunately, the authors only stated their opinion that constant observation appeared to be effective and practical without actually presenting the evidence. Serious medico-legal consequences could follow when constant observation was not used under appropriate circumstances. Thus some case histories
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of inpatients who committed suicide in the U.S. showed that for those who had been assessed to be at high risk of suicide, and succeeded in killing themselves due to inadequate supervision (in many instances there was some degree of observation but constant observation was not used), both the hospital and the staff concerned could be successfully sued for damages [72,76,77]. However, prolonged constant observation can often induce clinical regression and be counter-therapeutic, especially for patients with personality disorders [75,78]. Treatment issues: Whether the patient is receiving adequate treatment for hisher psychiatric condition is obviously an important question in relation to the management of suicide risk. In particular the early and appropriate use of ECT (electroconvulsive therapy ) as a life saving procedure for depressive suicidal patients and some suicidal schizophrenic patients has been emphasised [7,79]. However Goldstein et a1 [80] did not find the use of ECT to be a significant protective factor against suicide. The use of cognitive therapy to counteract hopelessness and hence suicidal risk has been discussed [ 15.301. However the exact value of such intervention is still unclear [ 151. Patients were often found to be improving at the time of suicide [42,68,73,78]. Thus an apparent, especially a sudden, improvement needs to be evaluated carefully, and continued supervision will be needed for patients whose suicidal thoughts persist despite apparent clinical improvement. Environmental safeguards: Common environmental safeguards that are recommended include suitably located nursing station from which all ward exits can be observed, windows should be of “non-breakable” glass, window openings should be restricted, unnecessary protrusions should be eliminated, all rooms when not in use should be locked, and curtain rods and cloth hooks should be of breakaway variety [5,7,64].
Medico-legal aspects of suicide management In the U.S., about one third of inpatient suicides resulted in lawsuits of which half were against psychiatric hospitals or units [ 11. Another recent review of psychiatric malpractice cases in the States [81] found that the largest group involved suicide or suicide attempt. In the UK, an HM coroner has recently expressed serious concern at the number of suicides committed by psychiatric patients in a communitybased psychiatric service [82]. With increasing em-
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phasis on community care and the consequent limited access to acute inpatient care facilities, suicidal patients could have difficulty in gaining admission, and could be discharged prematurely with potentially serious medico-legal consequences. Courts accept that not all hospital suicides are preventable [83.84] and that professionals are not infallible. There are two common rules that courts appear to use in determining the liability of the hospital and its staff: ( a ) whether the risk involved is “reasonably foreseeable” 177). If the risk can be reasonably foreseen but is not recognised or no appropriate measures are taken to manage the risk, then the professionals involved can be held negligent. (b) Whether “reasonable care and skill” are exercised in the management of the suicidal patient. Here the “conformity test” is commonly applied [72,84]. It refers to whether the care and skill in question conform to an accepted standard of care in keeping with local practice existing at the time. There should be adequate and timely documentation of the evaluation and management of the suicide risk to reduce legal vulnerability in case of litigation [76,85.86]. Proper documentation may be the single most important defence against the charge of malpractice. The reasons and thoughts supporting various decisions in relation to the suicide management should be carefully recorded [ 85,861.It is often suggested that a clearly written suicide precautions policy be established and consistently adhered to in the management of suicidal patients [5,76,87]. Finally, Morgan [82] emphasises that acute inpatient facilities must retain a critical mass so that there are sufficient reserves of staff to provide urgent intensive care when required for suicidal patients.
Conclusion There are many gaps in our knowledge of short term suicide risk predictors. Even though there are some suicide assessment scales for which predictive validity has been established by prospective studies, the focus has only been on the long term factors. The Hopelessness Scale [27] and the Modified Suicide Intent Scale [ 191 are claimed to be useful in the prediction of short term risk. but such claims have not been validated by scientific studies. Also, the short term factors known to be associated with specific psychiatric conditions have all been derived from retrospective studies, and their predictive validity has still to be established by
prospective, controlled studies. It is also not clear whether short term factors as derived from research findings (actuarial data) could be more accurate than the clinical evaluation of the short term suicide risk [ 181, and how much the use of clinical and actuarial information together would enhance the accuracy of the assessment. Regarding studies on the management of suicide risks, the effectiveness of various seemingly sensible strategies has not been validated by proper scientific evaluation. In particular, even though constant observation has been accepted as sound medico-legal practice, at least in the US, it is a costly procedure, the effectiveness of which has not been adequately evaluated. The medico-legal importance of having an explicit suicide precautions policy has often been stressed, but the fundamental question of whether having an explicit suicide precautions protocol is more effective in suicide prevention than not having one has not been addressed. There appears to be a need for prospective, controlled multicentre studies for such questions to be answered.
Acknowledgement Thanks are due to Professor Paul Mullen for his general comments on an earlier draft of this paper.
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