Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients

Objective: To estimate the strength of the associations between the suicide of psychiatric in-patients and demographic, historical, symptomatic, diagnostic and treatment factors. Method: A systematic review and meta-analysis of controlled studies of the suicide of psychiatric in-patients including suicides while on approved or unapproved leave. Results: Factors that were significantly associated with in-patient suicide included a history of deliberate self-harm, hopelessness, feelings of guilt or inadequacy, depressed mood, suicidal ideas and a family history of suicide. Patients suffering from both schizophrenia and depressed mood appeared to be at particular risk. The association between suicidal ideas and in-patient suicide was weak and did not reach statistical significance after a quantitative correction for publication bias. A high-risk categorization as defined by a combination of retrospectively determined individual risk factors was strongly statistically associated with in-patient suicide (OR = 10.9), with a sensitivity of 64% and a specificity of 85%. Conclusion: Despite the apparently strong association between high-risk categorization and subsequent suicide, the low base rate of inpatient suicide means that predictive value of a high-risk categorization is below 2%. The development of safer hospital environments and improved systems of care are more likely to reduce the suicide of psychiatric in-patients than risk assessment.