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People discharged from inpatient mental healthcare have a much higher risk of dying than the general population, research found. Their risk was particularly high in the 3 months after being discharged. The researchers say this highlights the need for improved follow-up and support for people returning to the community.

Working age adults were 191 times more likely to die by suicide than the general population in the first 3 months after discharge. The risk was most increased among those in the least deprived areas (compared to the most deprived), and among women.

Older adults were also at increased risk of suicide. In addition, in the first 3 months, they were 3.5 times more likely to die of natural causes (illnesses such as heart disease, or stroke) than people of the same age in the general population. This risk was highest in the most deprived areas.  

The study was based on the GP and hospital records of a large group of adults in England. The data covered the year after they were discharged from inpatient mental healthcare.

A second study again looked at the risks of dying among people with serious mental health conditions discharged from inpatient care. This time they were compared to people with serious mental health conditions who had not recently been in hospital. It found that the risk of death from all causes was much higher in those discharged from inpatient care.

The research team calls for improvements to discharge planning, based on individual need. 

Further information on mental health conditions is available on the NHS website.

What’s the issue?

Living in the community after spending time as an inpatient in a mental health ward can be difficult. People may still be unwell, and they may be returning to challenging and risky circumstances.

The risk of death by suicide is known to increase in the early weeks after discharge. However, studies have not compared the risk in this group of patients, to that in the general population.

People with serious mental health conditions are at higher risk of dying than the general population. People diagnosed with schizophrenia, bipolar affective disorder, or other psychoses have a life expectancy 10 to 20 years lower than the general public. This could be due to social risk factors, poorer access to healthcare, or side effects of medications. It is not known whether inpatient psychiatric care adds extra risk.

The research team monitored these risks over time. They considered whether gender, socioeconomic position, or age could affect the risk of death from different causes. They compared the risks among people discharged from inpatient mental health services, the general population and people with severe mental health conditions who had not recently been in hospital.

They hope their findings will help professionals support this vulnerable group.

What’s new?

First, the researchers looked at data on 100,000 people who had been discharged from an inpatient psychiatric unit in England between 2001 to 2018. Each was matched with up to 20 people in the general population who had not received inpatient mental healthcare. People were matched with others of the same gender, age and GP practice. This research included data on almost 2 million people in total.

It showed that in the first year after discharge, both working age and older adults (65+ years) had a higher risk of death than the general population. The risk was higher for each cause of death, including by suicide, related to drugs and/or alcohol, accidents, and natural causes (such as stroke).

The largest proportion of deaths (40%) in working age adults was by suicide. In older adults, most (94%) deaths were from natural causes. Compared to the general population:

  • suicide risk was particularly high in the first 3 months of returning to the community; working-age adults were 191 times more likely to die from suicide; older adults were 125 times more likely
  • risk of dying by suicide was greater among working age adults in the least deprived areas
  • women’s risk of suicide after discharge increased more than men’s (although the absolute number of men who died by suicide remained higher than the number of women)
  • older adults were 3.5 times more likely die by natural causes in the first 3 months after discharge, particularly those in the most deprived areas.

In the second study, the researchers looked at data from almost 24,000 adults who had been in inpatient mental health services. They matched each with up to 5 people with severe mental health conditions who had not received inpatient care. This gave a total of 119,000 adults.

People recently discharged from inpatient care had a higher risk of dying from all causes. Compared to those who had not recently been in hospital:

  • suicide risk was almost 12 times higher in the first 3 months after discharge; the risk remained higher for 2 to 5 years
  • the risk of dying by natural causes was raised in the first 3 months, and was highest in middle-aged people.

Why is this important?

Together, the studies show that adults of any age are at increased risk of dying after they are discharged from inpatient mental healthcare. The research highlights the need for careful discharge planning, particularly in the first 3 months. People need care that is tailored for them, and they need follow-up and support.

Mental health support to prevent suicides is needed for the whole group, regardless of gender. In contrast to trends in the general population, this research found that suicide was more likely in the least deprived areas. The researchers suggest that shame and stigma may be greater among less disadvantaged groups. Or it could be that services in deprived areas are better able to offer support.

Older adults need more support to improve their physical health, especially in more deprived areas. The researchers recommend holistic follow-up, including social support, physical health assessment, and adjustments to living arrangements.  They say that the lower risk of suicide could be because older adults may have survived previous crises. It could also be that many in this group had dementia, and may not have been able to plan suicide.

For people with severe mental health conditions, being discharged from inpatient care increased their risk of death (compared with no inpatient care). This highlights the need for more mental and physical health support for this group. Psychosis support services typically target younger people, but these findings suggest that middle-aged people also need this support.

What’s next?

The findings support NICE recommendations for timely support after discharge from inpatient mental health settings. They are also in line with the NHS Long Term Plan for mental health. Yet the research demonstrates people’s ongoing risk. The researchers say we need a rethink on how people are supported throughout their hospital stay and once they return to living in the community.

This research described the increase in deaths soon after discharge from inpatient mental healthcare. It was not able to explain why. The researchers say it is possible that staying in hospital can reduce people’s autonomy and their ability to self-manage their condition. It might also be that people do not have their physical health assessed at discharge. Further research could explore whether these explanations hold true. For now, the researchers suggest that the inpatient environment should prepare people for their life after they leave hospital.

This study did not include people who are not registered with a GP, such as those who are homeless. Further research could look at these groups. It could also investigate how the severity of mental health conditions and social circumstances affect risk of death.

The same research team is now investigating how people access services and are supported by their GPs in the year after discharge. They are exploring whether people who die by suicide are less able to access care. Colleagues at the University of Manchester are researching what patient safety interventions are effective after discharge. They developed Safer Plus, a step-by-step guide to improve the quality of hospital discharges. Safer Plus has been included in Royal College of Physicians guidance.

You may be interested to read

This NIHR Alert is based on:

A plain language summary and a blog by the author are available.

The NHS and the charity Mind provide information on how to get help for mental health conditions.

The National Confidential Inquiry into Suicide and Safety in Mental Health 2021 includes a toolkit for mental health services based on ’10 ways to improve safety’.

Funding: This work was funded by the NIHR Greater Manchester Patient Safety Translational Research Centre, and supported by the NIHR Applied Research Collaboration West Midlands, and by a NIHR Doctoral Fellowship.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

Study author

“We need longitudinal studies such as this one to understand the overall risk of death, including from suicide, in people discharged from inpatient mental healthcare. We also need to look at the degree to which these risks vary in different groups of people.

Our study has confirmed that the first months after discharge are the riskiest in terms of suicide. We highlighted the importance of timely follow-up. Everyone who is discharged needs a coordinated plan. The plan should focus on the person, and follow-up support should be in place.

We also emphasised the importance of a focus on physical health for older adults.”

Rebecca Musgrove, PhD student, University of Manchester

Researcher

I am not involved in clinical care so I cannot advise on actions to be taken. That said, this paper calls for adequate, holistic, follow-up support post-discharge, especially for older adults and those living in areas of relative deprivation. This might include additional support from occupational therapists, peer support workers and social prescribing.

I hope that these findings can be implemented into health and social care guidelines to provide better care for those who have recently been discharged from inpatient mental health settings.

In addition, the findings should have an impact on the care provided by health and social care professionals working in both inpatient and community settings. They need to ensure that the risks highlighted here are adequality considered during discharge and when providing care and support in the community.

Arti Makwana, Researcher, Kent and Medway Partnership Trust

Member of the Public

“This study confirms the importance of planning before discharge from in-patient care, and then following people up.

There is often a cultural dimension to deprivation and rates of suicide are higher among some ethnic groups than others. Deprivation was mentioned several times, and I would have liked to see more exploration of the cultural dimension to deprivation. Some reflection on the patient and public involvement in the study, and the impact it had, would also have been interesting.”

Virginia Minogue, Public contributor, Spalding, Lincolnshire

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