The failure of community care?

There are two groups of people who are at very high risk if suicide:

  • Those who have made a suicide attempt
  • Those who have been discharged from a psychiatric ward

This paper is a meta analysis of suicide rate post discharge. it includes over a hundred populations with reported post discharge suicide rates over time. It confirms that the immediate months an years are a time of risk. Again, there are no surprises to clinicians: in this time of limited beds we only admit those who we cannot manage in the community safely.

Our data suggest that the suicide rates among discharged patients have not decreased in the past 50 years. This is a disturbing finding considering the increase in community psychiatry and the availability of a range of new treatments during this period. The increase that we observed in postdischarge suicides can be seen in the context of the recent finding of a more extreme increase in the suicide rate among current inpatients from 68 per 100?000 person-years in the 1960s and 1970s to 646 per 100?000 person-years since 2000. An increase in the suicide rate of admitted and discharged patients might be attributable to multiple factors, including changing legal and other criteria for admission, shorter lengths of inpatient treatment, increased prevalence of substance use, and a greater acuity of illness among those admitted in the era of deinstitutionalization. Publication bias in favor of recent studies from regions with a higher suicide rate might have also contributed to the observed increase in suicide rates over time.

The marked variation in postdischarge suicide rates was not fully explained by the duration of follow-up or the year of the sample. Studies with similar periods of follow-up and studies conducted in the same or similar years have between-study heterogeneity that is similar to that of the whole sample.

What has happened over the period of the study is that the number of beds has decreased remarkably. When you look at the result section it is worth keeping in one’s mind that deinstitutionalization was an idea in 1975, a policy in 1985, and the last stand alone psychiatric hospitals in New Zealand were closed by 1995.

More recently conducted studies had higher rates of suicide per 100?000 person-years than older studies (2005-2016: 672 [95% CI, 428-1055]; 27 samples; I2?=?98%; 1995 to 2004: 656 [95% CI, 518-831]; 51 samples; I2?=?99%; 1985 to 1994: 404 [95% CI, 322-508]; 46 samples; I2?=?98%; 1975 to 1984; 373 [95% CI, 279-498]; 47 samples; I2?=?96%; before 1975; 423 [95% CI, 316-567]; 12 samples; I2?=?75%). The period of sample collection was significantly associated with between-sample heterogeneity (Q4?=?14.7; P?=?.005).

Community care was bought in without any trials. It was an ideology. The amount of shelter for those at great distress was decreased. Although the rhetoric of the age is that the old psychiatric hospitals were damaging and abusive, I have seen more damage occur among the homeless in Auckland than I ever saw in the end stage of the psychiatric hospital — and that includes stitching up lacerations among patients assaulted by the staff from a unit run by the family of certain Maori activists that was seen by management as a way forward.

If post discharge suicide rate is a good measure of effectiveness of psychiatric care, and these numbers are correct, the Western model is failing.

One thought on “The failure of community care?

  1. My hunch is that suicidality is a relatively stable state across generations (heritable) and we will eventually uncover the probability that one will develop the tendency within the decade.

    In my practice I have found the predictability piece to be confounded by the patients poor recall or knowledge of family history on that dimension.

    The ones who complete it seem to have an ability to suspend the natural instinct that all organisms have to preserve the self.

    And it seems like this manifests in the perfect storm of existential crisis plus genes.

    The system may be failing and that is a tragedy. But I also think there is an epigenetic component driving it as well.

    It literally never occurs to me to kill my self, even in dark times. My father endured actual torture in a communist prison camp and never once considered it.

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