East Asian Arch Psychiatry 2018;28:23-27

ORIGINAL ARTICLE

Dr Chie Tanimoto, PhD, Department of Nursing, Ishikawa Prefectural Nursing University, Ishikawa, Japan.
Dr So Yayama, PhD, Department of Nursing, Kyoto Gakuen University, Kyoto, Japan.
Dr Shunji Suto, PhD, Department of Community Medicine, Nara Medical University, Nara, Japan.
Dr Kei Matoba, MS, Department of Nursing, Osaka Aoyama University, Osaka, Japan.
Dr Tomomi Kajiwara, MS, Department of Nursing, Graduate School of Medicine, Osaka University, Osaka, Japan.
Dr Masue Inoue, MS, School of Human Services and Social Work, Griffith University, Queensland, Australia.
Dr Yoshimi Endo, PhD, Department of Nursing, Graduate School of Medicine, Osaka University, Osaka, Japan.
Dr Miyae Yamakawa, PhD, Department of Nursing, Graduate School of Medicine, Osaka University, Osaka, Japan.
Dr Kiyoko Makimoto, PhD, School of Nursing of Rehabilitation, Konan Women’s University, Hyogo, Japan.

Address for correspondence: Dr Chie Tanimoto, Department of Nursing, Ishikawa Prefectual Nursing University, 1-1 Gakuendai, Kahoku, Ishikawa,
929-1210, Japan.
Tel: (81) 762818389; Fax: (81) 762818386; Email: ctanimot@ishikwa-nu.ac.jp

Submitted: 5 April 2017; Accepted: 7 November 2017 

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Introduction

The World Health Organization estimates that worldwide more than 800,000 people die each year as a result of suicide; it aims to reduce this number by 10% by 2020.¹

Suicides in health facilities account for a major proportion of all suicides.² The incidence in psychiatric hospital in- patients varies from 0.06 to 5.66 per 1000 admissions^3,4 and is 10-fold higher than that in the general population³ and 140 times higher than that in general hospitals.² The purpose of treatment in a psychiatric hospital is to keep patients and others safe, while preventing in-patients from committing suicide.⁴

A systematic review of completed suicides among psychiatric in-patients found that patient characteristics varied among studies.4 Completed suicides were associated with a history of self-harm or attempted suicide.4 In-patients with such a history are known to be at an increased risk of suicide.3-7 Nonetheless, psychiatric hospital data on suicide attempts are lacking,1 and factors associated with self- harm and attempted suicide during hospitalisation have not been reported.⁵ Widespread incident report systems are an important means to analyse and understand how and why suicide incidents occur.8 According to guidelines of the National University Hospital Medical Safety Council in Japan,9 events affecting human safety are classified as levels 0 to 5; levels 0 to 2 are regarded as incidents and 

Level Description 0-2 No adverse outcomes, and treatment not required 3 Treatment required without serious consequence 4 Serious disability associated with incident 5 Patient death associated with incident levels 3 to 5 as accidents (Table 1). This study aimed to examine the circumstances of self-harm and suicide attempts by analysing incident / accident reports over a 12.4-year period at a psychiatric hospital in Japan.

Methods

This study was approved by the ethics committees of the Department of Health Sciences, Faculty of Medicine, Osaka University, and Ishikawa Prefectural Takamatsu Hospital in the Hokuriku Region of Japan. This hospital has 400 beds and 8 wards (5 wards for adult patients and 3 exclusively for older patients). The 5 wards for adult patients consist of 1 emergency and acute care ward (closed mixed-sex ward) and 4 long-term care wards (2 closed mixed-sex wards, 1 open male ward, and 1 open female special ward).

Hospital employees are required to report any incident or accident in medical practice through a local area network terminal. The information reported includes age; sex; clinical diagnosis (based on the ICD-1010) and ward of the patient involved; the level, date, time, and location of the incident / accident; the situation (methods and patient condition) in which the event occurred; causes and interventions; and years of experience of the staff member filing the report.

Of 5340 safety incident reports from November 2000 to March 2013, all cases of self-harm and suicide attempt were reviewed. We defined self-harm and suicide attempt as “harming one’s body or attempting to commit suicide either by one’s own will or as a result of pathological experience”. The rate of self-harm and suicide attempts was calculated per 1000 patient-days. Incident / accident reports did not include information about previous self-harm or suicide attempts; such information was retrieved from the patient clinical records.

Descriptive analysis was performed; similar contents were grouped together. Management and care factors related to self-harm or suicide attempts were also categorised. Causes were analysed in terms of whether preventive procedures of the hospital were adhered to. The chi-square test was used to assess the association of particular clinical conditions with suicidal behaviour, and SPSS (Windows version 21.0; IBM Corp, Armonk [NY], US) was used for statistical analysis.

Results

During the study period, 90 incidents/accidents of self-harm and attempted suicide involving 58 patients were reported. The rate of self-harm and suicide attempts was 0.05 per 1000 patient-days. The types of self-harm and suicide attempts were hanging (n = 25), wrist cutting (n = 19), ingestion of foreign objects (n = 17), and others (n = 29), which included banging the head against the wall, consuming a large amount of medicine, and fleeing during a period of approved leave. Forty-six (51.1%) of these cases were classified as level 3 and required treatments or procedures. No case was classified as level 4. There was only 1 level-5 case (completed suicide): a case of hanging in a patient with schizophrenia (sex and age data were missing). Excluding 16 patients with missing data, the mean ± standard deviation patient age was 36.2 ± 14.2 years. Excluding 12 patients with missing data, females accounted for 57% of patients involved, which was higher than the overall proportion of female in-patients (43%).

Eighty of the 90 incidents/accidents occurred in 3 of the adult wards. Of these, 38 and 41 were level 0-2 and level 3 incidents/accidents, respectively, and 1 was level 5 case. Most (n = 23) level 3 incidents/accidents occurred in the emergency/acute care ward. The number of cases of self- harm and suicide attempts was greatest in years 2003, 2005, and 2007 (Fig).

Among the 55 patients with relevant data, the most common clinical diagnosis was mood disorder (41.8%), followed by schizophrenia (36.4%), mental retardation (7.3%), developmental disorder (5.5%), others (5.5%), and personality disorder (3.6%) [Table 2]. The proportion of patients with reported self-harm or suicide attempt who

had been diagnosed with mood disorder was approximately 2.4 times as high as the proportion of all in-patients with the same diagnosis (41.8% vs. 17.2%, χ2 = 18.92; p < 0.01, Table 2). Mood disorder in patients with self-harm or suicide attempt was 3.5 times as prevalent in females than in males (14 vs. 4 cases).

Fourteen of 57 patients (24.6%) with mood disorder (n = 8) or schizophrenia (n = 6) were repeatedly involved in 46 of 89 cases of self-harm or attempted suicide; 11 were female, excluding 1 case with missing data. Thirty cases of repeated self-harm or suicide attempts in 10 patients occurred within 1 year of the previous episode (Table 3). One woman with mood disorder attempted suicide 9 times within 1 year.

Management and care factors related to the 90 incidents / accidents were classified into 6 categories (Table 4), as follows:

(1) Failure to adhere to preventive procedures for self-harm and suicide attempts (28%): for example, there was inadequate inspection of personal belongings on a patient’s return to the hospital after a period of leave; a nurse mistakenly lent a dangerous object to a patient; staff overlooked a razor in a body search on a patient’s admission or return to the hospital after approved leave or staff mistakenly handed a razor to a patient; a patient obtained scissors and tape cutters at the nurses station; and there was poor monitoring of isolated patients who used linen or clothing to hang themselves, and of those in general patient rooms who used towels, cords, or belts.

(2) Insufficient therapeutic communication (28%): for example, a patient’s frustration or stress was not adequately addressed. In 64 cases, 71 descriptions of patient pre-incident condition were reported: 31 involved psychiatric symptoms and 40 involved clinical conditions other than psychiatric symptoms; of the latter, about half were frustrations related to behavioural restrictions and inability to be discharged from hospital. Other pre-incident conditions included ‘interpersonal stress’ (regarding other patients, health professionals, or family members) and ‘anxiety’ about discharge or the future.

(3) Difficulty in predicting suicide (20%): for example, a patient’s condition may deteriorate suddenly

with no history of self-harm or suicide attempt. In the 31 descriptions of pre-incident condition that involved psychiatric symptoms, one-third were related to schizophrenia (eg, auditory hallucinations and delusions) and the remainder included anxiety, depression, medication refusal, or agitation. In 3 cases, the pre-incident condition was described as stable.

(4) Poor assessment of self-harm and suicide risk (12%): for example, staff overlooked a risk factor and “permitted the patient to go or stay out” or “admitted the patient to an open general ward.”

(5) Inappropriate interventions (6%): for example, staff forced a patient to move to another ward against his or her will because the current ward was fully occupied.

(6) Others (6%) were management and care factors that did not fit into the above categories.

Overall, 92 interventions were reported in 80 cases; the most common intervention was seclusion (n = 33), followed by pro re nata (as-needed) medication (n = 23), removal of dangerous items (n = 13), listening to a patient (n = 10), observation (n = 7), behavioural restrictions (n = 3), and transfer to a general hospital (n = 3).

Discussion

At the Ishikawa Prefectural Takamatsu Hospital, the incidence of self-harm and suicide attempts was relatively low (0.05 per 1000 patient-days), compared with the rate of falls (1.47 per 1000 patient-days) or medication errors (0.70 per 1000 patient-days). Of the patients with reported self-harm or suicide attempt, 76.8% were diagnosed with mood disorder or schizophrenia. This figure is in agreement with studies that report an increased risk of self-harm or attempted suicide in patients with mood disorders (depression), schizophrenia, or personality disorders.^3,4,6

Means restriction is important in the prevention of suicide.¹ In some cases, staff failed to adhere to preventive procedures and thus patients were able to bring a dangerous object to a closed ward. Even when staff adhered to preventive procedures, some patients in an isolation room used bed linen or clothing for hanging. Hanging seems to be a regularly used means of suicide for in-patients of mental hospitals.⁴ Staff need to be aware that anything can be used in a suicide attempt.

Although hospital guidelines state that “staff should frequently interact with patients, listen to patients carefully, and interact in a manner that displays acceptance and understanding of their psychological distress”, the frequently used interventions after incidents / accidents were seclusion and pro re nata (as-needed) medication. Such actions may result in patient frustration and stress. Repeated self-harm and suicide attempts accounted for more than half of incidents / accidents. Ward staff may have negative feelings towards patients who frequently complain about dissatisfaction and stress, and who repeatedly inflict minor self-injuries. Further research is needed to examine staff attitudes towards patients who repeatedly self-harm or attempt suicide.

A history of suicide attempts is a risk factor for suicide: 10% to 15% of repeat suicide attempters will die by suicide, and suicide risk increases in proportion to the number of attempts.¹¹ In future, a history of previous self- harm or suicide attempts should be included in the incident report.

In some cases, prevention of suicide or self-harm would have been difficult, because the patient’s condition had rapidly deteriorated or they had no history of suicide and were not considered at risk. Absconding and medication refusal have been suggested as antecedents to suicide attempts.⁵ Attention should be paid to these behaviours associated with self-harm and suicide attempts. The early stage of a hospital admission is also considered a risk factor for suicide.^4,5 The year, month, and day of admission should be noted on future incident reports.

Comparison among studies is difficult,⁷ as there is no consensus on the definitions of suicide-related behaviours, which include self-harm, suicidal ideation, suicide plans, and suicide attempts.^4,12 In our study, ‘self-harm’ was differentiated from ‘suicide attempt’, but definitions were not clear-cut. Classification of an incident / accident was also based on the individual staff member. The DSM-V proposes ‘non-suicidal self-injury’ and ‘suicidal behaviour disorder’ as different conditions.¹³ Future studies could use this terminology.

This study had two main limitations. First, the actual number of cases of self-harm and suicide attempts that took place may have been higher than that reported in the hospital’s safety incident report system.¹⁴ Second, data such as sex and age were missing in some cases and thus insufficient for analysis of the risk factors.

Conclusion

Self-harm and suicide attempts at this psychiatric hospital occurred at a rate of 0.05 per 1000 patient-days between late 2000 and early 2013. This study offers reasons for non-compliance with suicide prevention procedures or insufficient therapeutic communication, as well as recommendations to improve management and care of psychiatric in-patients and to prevent them from committing suicide.

Acknowledgements

We are grateful to Dr Koichi Kurata, Dr Tatsuru Kitamura, and Toshinobu Sugikado. We express our appreciation to Dr Noel J Chrisman for his valuable advice. This study was supported by the Grant-in-Aid for Challenging Exploratory Research (No. 2567910, 2013-15) from Japan’s Ministry of Education, Culture, Sports, Science and Technology.

Declaration

The authors have no conflicts of interest to disclose.

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