Providing support to suicidal patients post discharge

Article in Review: Chaudhary, A., Memon, R., Dar., Bhullar, D. Dar, K. & Naveed, S. (2020). Suicide during the transition of care: a review of targeted interventions. Psychiatric Quarterly, DOI: 10.1007/s11126-020-09712-x

Summary: We know that there are risks for setbacks for clients when unexpected challenges arise that interrupt engagement with service and treatment. We also know that there are foreseeable risks in the way we plan and manage care, including transitions within, between, and out of services. The research from Chaudhary and colleagues (2020) highlights a number of interesting and relevant factors important to how we manage transitions in care with our clients. With the exception of the dodgy suggestion for risk stratification to guide hospitalization, which we all know has zero evidence (see Carmen’s webinar on risk stratification).

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As we gather a growing amount of research related to the risk factors associated with suicide, we recognise that there is not one single suicide risk factor, but many. These risks may include genetic factors, a family history of or the presence of underlying psychiatric illnesses, social stressors, history of trauma, personality traits, and cognitive distortions. For many people, there is more than one suicide risk factor present, and we know that lives are generally changing of people who are suicidal are complex and always changing.

We also know that there is an increased risk of suicide after a suicidal person has been discharged from care. This risk may be exacerbated by the fact that there is a distinct lack of outpatient services for people who are transitioning to life in the community. The risks are further increased when patients discharge against medical advice, which occurs commonly.

It can be difficult to identify the imminent risk of suicide for patients as they discharge, especially those with complex and chronic suicidal behaviors. In making a plan for a patient, there are a number of interventions that might be considered.

So what is the best approach for offering support when an-at risk patient leaves care? A comprehensive new study (Chaudhary, Memon, Dar, Bhullar, Dar, and Naveed) has reviewed 40 articles related to interventions offered to patients as they transitioned out of a healthcare facility. The study sought to determine which support strategies, if any, led to an improvement in engagement of patients receiving outpatient support, and also which strategies might indicate a reduction in suicides. The authors intended the research to inform clinicians and policymakers about the assessed benefit of a variety of interventions that could be used during the period a patient is discharged from care.

Methodology
A total of 40 articles with relevant resultant search terms (suicide, hospital or emergency department, discharge) were assessed. These studies involved an impressive total of 24,568 patients. The interventions studied in these 40 articles all sought to reduce the number of suicides and suicide attempts by people recently discharged from care. As well as aiming to reduce suicides by at-risk patients, another common goal of these post-discharge interventions was to connect people back to their community, reduce social isolation, and provide a connection with an active listener.

Green cards, postcards, and letter-based interventions
Articles that considered the use of contact via mail were reviewed. Several studies looked at the provision of green cards, which provided details or information about support services. Other studies considered the practice of sending postcards or letters at different frequencies and duration post-discharge. These articles presented mixed results related to a reduction in the risk of suicide and suicide attempts.

Telephone-based and BIC interventions
A number of the articles assessed looked at the use of telephone contacts, which included phone calls, text messages, and the use of telephone calls for Family Intervention for Suicide Prevention (FISP). Findings related to the use of telephone calls were also mixed, although a number of studies found that telephone contact was considered more suitable by patients than letter-based interventions.

Miscellaneous interventions
Other articles assessed included those researching peer support, GP engagement, nurse home visits, and outpatient services. While there were some promising findings in some cases in this category as there were fewer suicides by patients receiving these interventions, this type of intervention typically has a higher and more labor-intensive cost, and there was not one standout approach among those studied.

Conclusion
Patients are at a higher risk of suicide in the first months after they leave medical care facilities. There may be any number of complex factors influencing this transition back to community life. By reviewing numerous other studies, which had a very large group of patients, the authors of this study were able to compare a range of engagement and support methods. While it was recognised that findings and results did vary and that there is not one standout best approach for post-accommodation care, it is acknowledged that connection to others is important for patients once discharged from care.

If you are looking to support your staff to improve engagement with their most at-risk clients, Suicide Risk Assessment Australia can give you guidance about which strategies will bring the most benefit given the unique factors relating to your staff and services.