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When Should My Suicidal Patient Go to the Hospital?

At one time, hospitalization was considered the standard of care when working with patients with suicidal thoughts or suicide attempts. However, almost all suicidal patients can now be treated effectively as outpatients. Several outpatient interventions can substantially reduce the risk of a suicide attempt (see, for example, reviews by Jobes & Chalker, 2019; Nuij et al., 2021). When, then, should psychotherapists recommend hospitalization for a suicidal patient?

I consider myself a hospitalization moderate. I have personally seen both the benefits of hospitalizations and the ways it has been misused, and I strive to keep current on the evolving research on suicide prevention. On the one hand, I have encountered patients with such a high risk of suicide that hospitalizations were necessary to save their lives. One young woman being treated by my agency was so intent on killing herself that if the police had arrived at her home five minutes later, she would have been dead. Nevertheless, such extreme cases are rare, and few patients with suicidal thoughts need to receive hospital care.

I have also seen the overuse of hospitalizations by undertrained and alarmist psychotherapists who did not have the training in evidence-supported interventions that can reduce the risk of suicide and initiate suicide prevention. Below are considerations for psychotherapists who need to decide when to recommend the hospitalization of a suicidal patient, including the standards to use, the contraindications, the importance of discharge planning, and special considerations with involuntary or pressured psychiatric hospitalizations.

When Is a Psychiatric Hospitalization or Hospital Care Indicated?

The decision to recommend a psychiatric hospitalization requires weighing the benefits of a hospitalization against its costs. Sometimes, hospitalizations may be necessary to save a patient’s life or start them on the road to recovery and suicide prevention. Psychiatric hospitalizations for suicidal patients may be indicated if patients pose such an immediate threat to their safety that they need to be monitored closely or if they have unusual or comorbid medical issues that require close attention.

Most psychiatric units provide short-term care focused on stabilization (Simon, 2012). Stays can be extended if patients have comorbid issues or complications such as substance misuse or psychotic features. Patients or their families may have unrealistic expectations from a hospital stay, so psychotherapists should explain their goals for the hospitalization and ways that patients can maximize the benefits of their hospitalization.

Ideally, psychotherapists will recommend a hospitalization after a thorough evaluation that allows patients to tell their stories at their own pace, and the psychotherapist has consulted with family members and other treatment providers. They then need to determine if the usually effective outpatient interventions to reduce suicide risk, such as safety planning, lethal means counseling and psychotherapy, are sufficient to ensure patient safety. However, the conditions that give rise to the need for hospitalization may arise quickly, so sometimes psychotherapists have little time to reflect, involve family members, or consult with others.

Assessing Risk for Suicide and Suicide Prevention

Predictions of a suicide attempt are fraught with many uncertainties, and no formula can predict the likelihood of a suicide attempt with great accuracy. Psychotherapists can, nonetheless, make the best decisions if they follow an established format for assessing risk (e.g., Jobes [2023] or Bryan and Rudd [2018]).

Screening instruments, such as the Columbia Suicide Screening Scale or the Ask Suicide-Screening Questions, can assist psychotherapists in making these decisions. However, these instruments should never be used in isolation to determine the risk of suicide or the needed level of care. No suicide screening instrument is high in both specificity and sensitivity (Runeson et al., 2017), and no one screening instrument is noticeably better than any other (Gutierrez et al., 2021).

Some psychotherapists rely on levels of risk formulae to inform psychologists whether the services should be inpatient, intensive outpatient, or regular outpatient. These may help some psychotherapists to think through the information that they have. Nonetheless, psychotherapists should not overvalue these formulae. First, they are imprecise. They lack consistent definitions across studies, and no study has demonstrated that they can predict the short-term likelihood of suicide with any reasonable degree of accuracy (Berman & Silverman, 2013). Also, suicidal risk fluctuates over time and sometimes very rapidly. A patient who seems safe one day may appear highly suicidal the next. Finally, placing a patient at a level of risk may lead to confirmation bias, wherein the interpretation of new data is overly influenced by a level of risk previously established for a patient.

Psychotherapists should weigh the clinical benefits of hospitalization against the costs to the patient, including disruptions in their lives, the potential for exposure to harmful events in the hospital, and the social stigma involved. Even brief hospital stays mean patients cannot work, go to school, care for children, or participate in other important life activities, and may have financial burdens imposed on them.

A less obvious cost to patients is that they may have to invest much time to secure hospital admission. In the ideal situation, a patient is also being treated by a psychiatrist with privileges in a nearby hospital, and the psychiatrist can admit the patient quickly. Nevertheless, arranging a hospitalization can often be taxing on the psychotherapist and the patient. I have known patients who have waited hours in the hospital emergency department while case workers looked for a hospital bed, only to be sent home while the case worker tried again the next day.

Repeated hospitalizations may be clinically contraindicated for persons with chronic and severe personality disorders, and psychotherapists need to balance the patient’s immediate safety with the long-term goals of treatment (Carmel et al., 2018). Psychotherapists need to consider, for example, if the hospitalization would reinforce inappropriate behavior by giving too much attention to suicidal thoughts at the expense of looking at other aspects of life and different ways to cope with difficulties.

The hospitalization decision also needs to consider the quality of the services in the recommended hospital and the potential for harm occurring in the hospital. No two hospitals are alike. Many patients experienced good care in hospitals and reported that their experiences there set them on a recovery trajectory. Other patients reported a dehumanizing atmosphere and exposure to problematic and frightening behavior from other patients (Large et al., 2014). While traumatic events in a hospital may contribute to the suicide of some patients, it is difficult to determine how often this happens because those sent to the hospital may already have a high risk (Ward-Ciesleski & Rizvi, 2021).

Psychotherapists should generally respect patient preferences regarding hospitalization (see the section on involuntary psychiatric hospitalizations for limited exceptions). If psychotherapists need to consider a hospitalization, they should document their decision-making process, including information relied upon to make the decision, the pros and cons of hospitalization, and why the final decision was made. The level of detail should be sufficient for an outsider to understand why the psychotherapists acted the way they did.

Discharge

Because of the short stays for most psychiatric hospitalizations, discharge planning should start soon after the patients are admitted. Ideally, there will be a smooth transition between inpatient and outpatient services, but this does not always occur. The risk of death by suicide is exceptionally high in the first months following discharge from a psychiatric hospital (Chung et al., 2017). Among VA patients, 40% of those who died from suicide within the first week died on the day of discharge (Riblet et al., 2017).

Psychotherapists should inform hospital staff on admission whether they intend to continue seeing the patients after discharge so the staff can make appropriate discharge recommendations. Some hospitals permit psychotherapists to visit or have phone contact with their patients while receiving hospital care, although this needs to be coordinated with the hospital.

Special Considerations with Pressured or Involuntary Psychiatric Hospitalizations

Involuntary or pressured psychiatric hospitalizations should be the last resort and used only when the danger to the patient is great and imminent and the psychotherapist can identify no other way to diffuse the danger. In addition to all of the contraindications for a hospital stay in general, involuntary psychiatric hospitalizations involve additional stigma associated with it, the loss of autonomy for patients, and may have secondary consequences such as the inability to own firearms in many states legally.

Pressure can occur not only through a formal involuntary psychiatric process but by threatening an involuntary hospitalization (and loss of ability to own firearms, loss of freedom to discharge oneself, and so on). Perceived coercion is linked to poorer outcomes. Those who report being pressured into hospitalization have small but significantly higher rates of subsequent suicide attempts than those who do not report such pressure, even when other factors were held constant (Jordan & McNiel, 2020).

If psychotherapists determine that an involuntary psychiatric hospitalization is needed, they should ensure that the statutory conditions have been met. Also, they should involve patients in the decision as much as possible, although a few patients, such as those in acute psychotic states, may not be able to participate in a meaningful way. Psychotherapists must be transparent about why they recommend the hospitalization and what services they want the hospital to provide. I have secured the cooperation of many suicidal patients by listening carefully to their concerns, explaining why I was recommending the hospitalization, involving them in the decision, and respecting their wishes as much as possible. For example, by carefully listening to one patient, I learned that she was refusing to go to the recommended hospital because her husband had died there, and it appeared that she had PTSD-like symptoms from that experience. Nonetheless, she willingly agreed to go to another hospital.

Practice Pointers

  • Outpatient interventions can usually aid in suicide prevention to keep patients safe, although psychiatric hospitalization may be needed in rare situations.
  • The decision for inpatient treatment should be based on a thorough patient assessment, including the immediate risk of harm, the benefits and risks of hospitalization, and the patient’s preferences.
  • Psychotherapists should not overvalue levels of risk formulae or suicide screening instruments when making recommendations about hospitalizations.
  • Hospitalizations may be clinically contraindicated for some patients with a chronic risk of suicide.
  • The quality of care in hospitals varies widely. Some patients report harmful experiences in hospitals, while others report benefits.
  • Psychotherapists should document why hospitalization was or was not recommended, including the pros and cons of the decision and why the final decision was made.
  • Because the risk of suicide following a discharge is very high, psychotherapists should communicate clearly with the hospital their desired involvement in treatment following release and, if appropriate, be closely involved in the discharge planning.
  • Involuntary or pressured psychiatric hospitalizations should be the last resort when the threat of a suicide attempt is imminent, alternative ways to secure the patient’s safety are not feasible, and efforts to obtain the patient’s consent have failed.

Samuel Knapp is a retired psychologist who formerly worked as the director of professional affairs for the Pennsylvania Psychological Association.

Cite This Article

Knapp, S. (2024, January). When should my suicidal patient go to the hospital? Psychotherapy Bulletin, 59(2). 17-21.

References

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Bryan, C. J., & Rudd, M. D. (2018). Brief cognitive-behavioral therapy for suicide prevention. Guilford.

Carmel, A., Templeton, E., Sorenson, S. M., & Logvinenko, E. (2018). Using the Linehan Assessment and Management Protocol with a chronically suicidal patient: A case report.

Cognitive and Behavioral Practice, 25(4), 449-459. http://doi.org/10.1016/j.cbpra.2018.02.001

Chung, D. T., Ryan, C. J., Hadzi-Pavlovic, D., Singh, S. P., Stanton, C., & Large, M. M. (2017).

Suicide rates after discharge from psychiatric facilities: A systematic review and meta-analysis. JAMA Psychiatry, 74(7), 695-702. http://doi.org/10.1001/jamapsychiatry.2017.1044

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Jobes, D. A. (2023). Managing suicidal risk: A collaborative approach (3rd ed.). Guilford.

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Jordan, J. T., & McNiel, D. E. (2020). Perceived coercion during admission into psychiatric hospitalization increases risk of suicide attempts after discharge. Suicide and Life-Threatening Behavior, 50(1), 180-188. http://doi.org/10.1111/stlb.12560

Large, M., Ryan, C., Walsh, G., Stein-Parbury, J. & Patfield, M. (2014). Nosocomial suicide. Australian Psychiatry, 22(2), 118–121. http://doi.org/10.1177/1039856213511277

Nuij, C., van Ballegooijen, W., de Beurs, D., Juniar, D., Erlangsen, A., Portzky, G., O’Connor, R. C., Smit, J. H., Kerkhof, A., & Riper, H. (2021). Safety planning-type interventions for suicide prevention: meta-analysis. British Journal of Psychiatry, 219(2), 419-426. http://doi.org:10.1192/bjp.2021.50

Riblet, N., Shiner, B., Watts, B. V., Mills, P., Rusch, B., & Hemphill, R. R. (2017). Death by suicide within 1 week of hospital discharge: A retrospective study of the root causes analysis report. The Journal of Nervous and Mental Disease, 205(6), 436-442. http://doi.org/10.1097/JNMD.0000000000000687

Runeson, B., Odeberg, J., Pettersson, A., Edbom, T., Jildevik Adamsson, I., & Waern, M. (2017). Instruments for the assessment of suicide risk: A systematic review evaluating the certainty of the evidence. PLoS One, 12(7). http://doi.org.10.1371/journal.pone.0180292

Simon, R. J. (2012). Therapeutic risk management of the suicidal patient. In R. Simon & R. E. Hales (Eds.). Textbook of suicide assessment and management (2nd ed.) p. 553–577. American Psychiatric Association.

Ward-Ciesleski, E. F., & Rizvi, S. L. (2021). The potential iatrogenic effects of psychiatric hospitalization for suicidal behavior: A critical review and recommendations for research. Clinical Psychology: Science and Practice, 28(1), 60-71. http://doi.org/10.1111/cpsp.12332

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